**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the provider failed to provide adequate supervision for 1 of 1 resident (20) to prevent actions of self-harm. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on [DATE] at 2:12 p.m. to administrator A for F689 and director of nursing B for F689 Accidents related to the prevention of his self-harm. *Observation on [DATE] of resident 20 in his room revealed he had multiple open areas, some of which were actively bleeding on his bilateral lower legs while holding a sharp instrument. *Multiple staff interviews revealed they were aware that he had various sharp tools in his possession and used these sharps to cut himself to remove bugs he believed were under his skin. *Record review of resident 20's care plan revealed he was allowed to have sharps he purchased in his possession to remove perceived bugs from his skin. On [DATE] at 4:23 p.m., administrator A provided the survey team with a written plan for removal of the immediate jeopardy. The removal plan, after revisions, with guidance from the long -term care advisor for the South Dakota Department of Health, was approved by the survey team on [DATE] at 5:06 p.m.: *All sharps have been removed from [Resident 20's] room. *Psychiatry, primary care provider and counselor have been notified of these changes for guidance in managing any adverse behavioral changes. *[Resident 20] has been re-educated on hand hygiene, sharps in his room, infection prevention to include covering wounds. *Updates to the care plan include removing sharps, offering tubi-grips for arms and lower legs for covering of wounds when leaving his room, handwashing education, wound assessment completed [DATE], one-hour check while in the facility for behaviors given resident psychiatric history for 48 hours then re-evaluate. *Center of Excellence for Behavioral Health in Nursing Facilities contacted with expected response within two business days. *[DATE] Addendum, in addition to the skin/wound assessment completed on [DATE]; on [DATE], director of nursing B spoke to [resident 20] about dressing changes. *Resident agreed to let nursing staff change dressing twice a day (BID). *Nursing staff will monitor for any signs of infection during BID dressing changes and notify the physician if any noticed. These will be documented on [resident 20's] treatment. *Nursing will remove soiled towels and washcloths when in his room providing dressing changes. This has been included in the treatment plan and added to the certified nursing assistant (CNA) flowsheet. *Resident was informed that he would not need to buy wound/dressing supplies. *Sharps removed from resident 20's room. *All other current resident rooms were checked for sharps and any of concern were removed. *[DATE] addendum, they had discussed with [resident 20] that his bags would be checked upon return from shopping. *Resident signed previous acknowledgment form that he agreed to staff removing sharps that he may bring back. *Staff will conduct random weekly room checks and will chart in [resident 20's] chart as a treatment. *This has been added to [resident 20's] treatment plan and CNA flowsheet. *They added a treatment order for nursing documentation for behavior/mood of resident 20 daily. *[Resident 20's] behavior documentation will be reviewed at weekly interdisciplinary team (IDT) meetings and as needed (PRN) with adjustments to care/treatment plan as warranted. *admission packet updated regarding review of sharps for safety. *[Resident 20's] primary contacts have been re-educated on notifying staff prior to bringing/getting sharps items to resident via email. *[Resident 20] has been re-educated on proper hand hygiene for infection prevention and sharps. *Staff have been re-educated on sharps in rooms and planned review of infection prevention practices related to transmission through OnShift. *They receive this education annually at minimum. *A skills fair reviewing infection prevention is scheduled for [DATE]th and annually for staff. *Sharps restriction added to admissions packet. *Staff re-educated on infection prevention practices and safety of all residents related to sharps in resident rooms. *[DATE] addendum, staff were educated on [DATE] through onshift message about the removal of sharps for any resident. *Additional education provided to nursing staff on [DATE] related to resident 20 returning from shopping, the need to look in resident 20's bags for any sharp objects that staff would need to remove and secure in the medication room, staff will reiterate to resident that he is not able to have those items in his room *PRN treatment order added to check bags upon returning from shopping outings. *Staff will also be educated on the weekly random room checks that will be conducted on [resident 20's] room for sharps found, those items will be removed and secured in the medication room. *Treatment order added to document these random weekly room checks for [resident 20], also added to CNA flowsheet to check room BID. On [DATE] at 10:43 a.m., the survey team determined the immediacy was removed. After removal of the immediacy, the severity and scope was a level G. 2. Observation and interview on [DATE] at 9:29 a.m. with resident 20 revealed: *He was sitting on the edge of his bed scratching at his leg. *He had multiple open areas with some active bleeding on his bilateral lower legs and bandages on some of them. *He was dressed in only boxers holding and was holding a wooden handled tool with a flat top type screwdriver in his hand with his leg crossed, with his right ankle on his left knee. *There was a card table across from him that had two table lamps clamped to each side of it. *Pouches were hanging below each lamp contained various tools, scissors and glasses and a magnifying glass. *There was a white towel under his bare feet with dried blood on it and another lying to his left with dried blood on it. *Bandage wrappers were on the floor by his feet. *He stated his legs are better because he has been taking care of them. *He stated he kept his tools in alcohol. *He stated he had good medicine here but the nurse took it from him and said it was dangerous and he could not have it. *He stated he was doing okay for the shape he was in. *He stated he was sad when he first had to come here and when first came to live there but no it was not so bad. *His shower has two discolored towels on the floor that appeared to have been wet then dried multiple times and had what appeared to be dried blood on them. Interview on [DATE] at 4:00 PM CNA P in regards to resident 20 revealed: *He picked at his legs, and thought there was something under his skin. *Staff would take the tools he used to pick at his skin, but he would get them back. Interview on [DATE] at 4:15 p.m. with RN F in regards to resident 20 revealed he: *Had a picking disorder and could have sharps in his room. *Tried to cut bugs out of his skin. *Would not let any nurses take care of the open areas on his legs. *Had a brother or friend who was aware he cuts himself. *Was aware that staff had removed the sharp objects he used to cut himself. *Is independent and is allowed to leave the premises. *Would go to a store on public transit and buy what he wanted and would bring it back to his room. *He was aware that his sharps and cutting of himself were care planned. Telephone interview on [DATE] at 9:30 a.m. and 1:20 p.m. and with the regional long-term care ombudsman revealed. -She was not contacted by the provider and was not aware of resident 20's situation. -The Center of Excellence for behavioral health in nursing homes should have been contacted by the provider. Interview on [DATE] at 12:25 p.m. with the behavioral counselor for the provider revealed she: *Started seeing resident 20 in March of 2022. -Initially because he was having suicidal ideations. -He had lost his longtime girlfriend and had expressed if he had a gun he would end things. -His primary hallucination was bugs under his skin but then it changed to psoriatic arthritis in [DATE]. The psychiatrist adjusted his medications and his cutting had decreased. Then he had some issues when applying for Medicaid and was questioned about his finances, which she felt caused him anxiety and increased his behavior of cutting. -When his partner or his own health would decline he would have increased anxiety and cutting of himself. the issue of cutting gets worse. -His vision is getting worse. She wasn't sure if that would increase his safety risk. -He does not cause self-harm other than his belief of bugs in his body. -He had denied having a plan of self-harm. -She was aware of an instance of him having believed he had seen his long-term friend in his room after she had passed. -He had acted angry or snippy with staff but was not aggressive with them. -His cutting was not as regular when his friend was still alive. -She stated some of his wounds such as the ones under the large bandages were from his leg having been caught on the edge of his bed. There was no incident report to support this. -She would see him every 4-5 weeks. -He had expressed in [DATE] that he felt more like living. Interview on [DATE] at 1:30 p.m. with RN K in regards to resident 20 revealed: *He had concerns regarding resident 20 and stated, I can't believe he isn't septic with his cutting. *Resident 20 had all kinds of sharps from a Hobby knife kit he had bought from at a local store. -Nurses do not provide his wound care, he did his own. -RN K did not work resident 20's hall but was aware of his cutting behavior. -He said all of resident 20's wounds on his legs were from his cutting himself and he had no injuries from falls or scraping on his bed frame that he knew of. -He does not believe resident 20 would hurt anyone or himself intentionally, he is just trying to get the bugs out of his skin, which there aren't any. -He was not aware of a list of what tools he had or a way to track what he brought back from outings. -He has had fewer visitors but RN K why. Interview on [DATE] at 1:45 p.m. and again at 2:05 p.m. with LPN L revealed: *She did not do wound care for resident 20 and she had concerns about him cutting himself. *She was not sure how many open areas he had. *There had been no pictures for documentation of his wounds. *There was no sharps inventory or count of how many sharps resident 20 had in his possession. *She had concerns about his history of falls and the potential he could fall and be injured by a sharp object. *She would organize his room due to her concerns, he would allow that, but he would tell her to not take anything. *She stated the previous social worker was aware him cutting himself with the sharps he had. *She stated that she does not participate in care conferences but has reported her concerns and all the management were aware of his cutting himself with the sharps he had in his room. *He was not on any antibiotics but had an order for Neosporin to self-administer in his room. *He has not been tested for infectious diseases. *Certified nurse aides (CNA's) should report any new wounds or concerns. Interview and observation on [DATE] at 1:40 p.m. with resident 20 revealed: *He has eleven open areas on his inner lower left leg with four small bandages and his right lower inner leg had eight open areas with three large bandages. *He stated the bandages are because those I made bleed, so I put band-aids on them. *He said he cleaned them himself but had not been educated by the facility staff on how to clean tools or his open areas. - I have a bottle of alcohol I clean my legs first, then use hot water, and then put Neosporin on them. -A bottle of 91% alcohol was under his bed and was approximately a third full. -He stated he used the alcohol to clean his scalpels a couple of times a day. -There was no redness observed to the surrounding tissue of his visible open areas. Interview and observation on [DATE] at 9:05 a.m. with resident 20 revealed: *He had tubi-grip (elastic tubular bandage) on his bilateral lower legs and stated, his wounds were better and he hoped they stayed that way. His mood was pleasant. *There was a hand washing reminder sign in his room and bathroom. Record review of resident 20's care plan dated [DATE] revealed. *Behavioral symptoms included cutting and or picking off warts and scabs on his skin. He utilizes scalpels he gets at the hardware store. -He declines to follow physician recommended advice of no cutting warts off his skin, and will decline skin-care and other treatments at times needed to properly address his self-inflicted wounds (see delirium). He will regularly create or manipulate his own or facility items to fix them or create things (i.e. Using a belt for a strap on his wheelchair). He was encouraged not to create restraints for himself and to seek staff input before fixing facility property. - Long-term goal date of [DATE] noted, he would decrease his use of sharps. He was able to keep sharps in his room, per his refusal to comply with [NAME] policies and concerns for safety without sharps to pick at his skin (as he relies on dull/other unsanitary means to pick at his skin). -He will not utilize scalpels in a way that puts his well-being or life into question. -He will not harm himself outside of cutting off his warts/scabs. -He will not harm or threaten others with his scalpels. *Approach date [DATE] noted, allow [resident 20] to have sharps in his room. -Remove sharps with conversations regarding self-harm with these sharps. -Offer education in regard to safety/infection control as needed. -Notify the physician/registered nurse (RN) if statements of self-harm manifest. -Assess for pain and offer pain medications, as able, with thoughts of death-statements. As needed PRN1, PRN 2, PRN 3. -Discipline noted, all staff and social services. *Long-term goal target dated [DATE] noted, that [resident 20] will have fewer episodes of refusing care. -Resident will consider physician-recommended interventions to treat what is causing ailments. -Resident will be more open to allowing RN's to treat open areas on his skin related to infection prevention. *Approach start dated [DATE] noted, redirect resident as needed. -Ask for help or re-approach if resident becomes abusive or resistive. -Keep environment calm and relaxed. -Remove from public area when behavior is unacceptable. -Document refusal of care when it occurs. -Assist in applying antibacterial creams and appropriate dressings for open area to the skin, PRN. -Ask RN's to assist in evaluating and treating wounds. As needed PRN 1, PRN 2, PRN 2. -Discipline noted, all staff, nursing and social services. *Problem start date [DATE], environment noted, -[Resident 20] keeps sharps in is room related to behavioral concerns/delusions of bugs in his skin. -As long as there is no self-harm ideation/intent, he is able to have these in his room due to resident rights and continued non-compliance with having them removed. (similar care plan noted under behavioral symptoms) -[Resident 20] is sensitive to others touching items in his room, even for infection control reasons. He sternly requests that he is consulted before environmental services (ES) deep-cleans his room, as he is not compliant with this task and has had verbal interactions with ES and others before over items in his room being tidied/moved. -He likes to be in charge of where his dirty clothes go and often keeps paints on tables that are still clean and has his wallet and things in it. It has been care planned that he will have a laundry basket in his room to put his dirty clothes in and staff will take the clothes from the basket only to wash. -He will independently buy items at Walmart related to his delusions of bugs. He has no cognitive impairment and is self-sufficient enough to go out and about to purchase his own things. Education has been provided to to him on the safety of certain pesticides and those items have been removed but it causes more agitation for him. *Long term goal target date [DATE] noted, [resident 20] will be able to keep sharps in his room, per his refusal to comply with [NAME] policies and concerns for safety without sharps to pick at his skin (as he relies on dull/other unsanitary means to pick at his skin when sharps are not available). -He will not utilize scalpels in a way that puts his well-being or life into question. -He will not harm himself outside of cutting off his warts/scabs. -He will not harm or threaten others with his scalpels. -He will be accepting of the removal of sharps from his room if there is question of self-harm or harm to other with these utensils. *[Resident 20] will work with ES and certified nursing assistants (CNA's) to keep his room somewhat tidied and disinfected. -He will refrain from verbal interactions with other over his room cleanliness. _he will be understanding of the basic infection control measures that have to be taken with is room, in reference to bloodied or dirty cloth items and other unsanitary items on the floor of his room. -He will put his dirty clothes in the laundry basket provide for ES to know what is dirty and what is clean. -He will be aware of certain pesticides that he brings into his private room and sue them with caution. *Approach start date [DATE] noted, allow [resident 20] to have sharps in his room. -Remove sharps with conversations regarding self-harm with these sharps. -Offer education in regard to safety/infection control as needed. -Notify physician/RN if statements of self-harm manifest. -Assess for pain and offer pain medications, as able, with thoughts of death-statements. -Consult with resident prior to deep-cleaning his room. -Help mediate infection control needs and resident rights between resident ES staff. -Help to remove unsanitary cloth items as they are seen, and replace them with unsullied linens/washcloths/towels. -Staff will be respectful to only grabbing the dirty clothes out of his laundry basket to clean. -Staff will be respectful and continue to educate [resident 20] on the dangers of some of the pesticides that he purchases and has in his room. -As needed, PRN 1, PRN 2, PRN 3. -Disciplines, all staff and social services. *Problem start date [DATE] noted, delirium, [resident 20] believes there are microscopic bugs under his skin. -He believes this is why his skin itches and, possibly why he gets warts -He cuts off his warts and scabs to stop the itching from the bugs under his skin. (see behavioral symptoms). *Long term goal target date of [DATE] noted, [resident 20} will utilize other methods of itch-control outside of cutting off his warts. He will speak with his physician about the bugs under his skin and/or the itching of his skin. *Approach start date [DATE] noted, Help communicate [resident 20's] concerns about itchiness and bugs to his physician as needed. -Help to apply anti-itch lotion as prescribed. -Encourage scratching/patting his skin as a way of itch-control as needed. -Utilize frequent checks if he is utilizing his scalpel to cut off warts or scabs. *Discipline noted, all staff and social services. *Problem start date [DATE] noted visual function. -[Resident 20] has impaired vision and utilizes corrective lenses for reading activities. -Per [resident 20], an optometrist visit in 2020 relays that he is slowly losing his eyesight, and may be absent of useful vision in the future. *Long term goal target date of [DATE] noted, resident will have optimal ability. -He will utilize glasses/corrective lenses as preferred. -He will be accepting of staff assistance in managing glasses, as able and as needed. *Approach start date [DATE] noted, visual aides. -Keep glasses clean and encourage use. -Keep glasses readily available. -Adequate lighting in room. -Encourage activities appropriate for visual acuity. -Optometrist visits as needed. -Monitor for appropriate navigation of small objects related to possibly losing vision in his eyes. -As needed, PRN 1, PRN 1, PRN 3. *Discipline noted, all staff and social services.