**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 residents (Resident #77) reviewed for quality of care. The facility failed to follow physician's order for daily weights for Resident #77 for 01/26/2024 and 01/27/2024. These failures could place residents at risk for decreased level of functioning and quality of life. Findings included: Review of Resident #77's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Sepsis, Pneumonia, respiratory failure, and congestive heart failure. Review of Resident #77's admission MDS dated [DATE], revealed: Section C: Cognitive Patterns a BIMS score of 14 indicated no cognitive impairment. Further review revealed: Section K: Weight 200.4 lbs Review of Resident #77's Comprehensive Care Plan initiated 01/22/2024, revealed: Focus: The resident has congestive heart failure. Goal: The resident will be free from complications related to CHF through the review date. Interventions: Monitor/document/report to MD PRN any s/sx of CHF: dependent edema of legs and feet .weight monitoring per physician's orders. Review of Resident #77's electronic physicians' orders revealed: Daily weight every day shift for edema for 7 days. Notify physician of weight of 3lbs or grater in 24 hours with a date of 01/26/2024. Review on 01/26/2024 of Resident #77's electronic record revealed no evidence of a weight obtained. Review on 01/27/2024 of Resident #77's electronic record revealed no evidence of a weight obtained. Review on 01/28/2024 of Resident #77's electronic record revealed weight of 206.4 lbs. Review on 01/29/2024 of Resident #77's electronic record revealed weight of 209.8 lbs. Review on 01/30/2024 of Resident #77's electronic record revealed weight of 210.1 lbs. Review of Resident #77's electronic progress note, dated 01/30/2024 at 9:15 am signed by LVN I, revealed: CHF clinic contacted again to f/u on resident's edema. Spoke with office and informed them of edema to BLE and weight gain. Also requested all notes from previous visits. Office to notify provider and appointment scheduled for 1/31/24 @ 0930. Review of Resident #77's electronic progress note, dated 01/31/2024 at 11:47 am signed by LVN I, revealed: Resident attended appointment with CHF clinic today for f/u d/t BLE edema. Weight gain was noted by provider. 3-4+ edema present to BLE. Labs performed at appointment. Orders given by provider for the following: stop Lasix, start torsemide 20mg PO BID. Family member was present at appointment and aware. Review of Resident #77's CHF Clinic Patient Summary, date 01/31/2024, revealed: The patient is seen today as emergent work-in appointment. Her weight is up 7 lbs. from the last appointment one week ago. She has 3 to 4+ edema to lower legs bilaterally with weeping from the legs. She was seen in trauma center for cellulitis and was started on antibiotics. She is in a wheelchair. The patient feels like Lasix is no longer effective in keeping her swelling controlled. The patient was given 40 milliequivalents of potassium. She was also given 80 milligrams of IV Lasix for her weight gain and heart failure symptoms. During an observation and interview on 01/29/24 at 12:13 PM, revealed Resident #77 sitting in recliner and resident family member sitting on her bed. Resident #77's legs were swollen, red, and not elevated. No signs or symptoms of respiratory acute distress noted. Resident denied pain or any shortness of breath. Resident #77's family member stated Resident #77 had a history of problems with swelling and fluid overload. During an observation and interview on 01/31/24 at 2:00 PM, Resident #77 was up in wheelchair just returning from her visit the CHF clinic. No signs or symptoms of respiratory acute distress noted. Resident denied pain or any shortness of breath. Resident stated she received liquid Lasix for her swelling and that she was going to pee all night. During an interview on 01/31/24 at 03:00 PM, the DON stated stated she was ultimately responsible for monitoring and ensuring that all physicians orders were followed. During interview on 01/31/2024 at 8:00pm, DON and Administrator stated the facility did not have a policy for following physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent significant medication error for 1 of 33 residents (Resident #77) reviewed for pharmacy services. The facility failed to follow physician's order by not administering Lasix 20mg (diuretic medication to reduce swelling) as needed every 24 hours for Resident #77. These failures could place residents at risk for decreased level of functioning and quality of life. Findings included: Review of Resident #77's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Sepsis, Pneumonia, respiratory failure, and congestive heart failure. Review of Resident #77's admission MDS dated [DATE], revealed: Section C: Cognitive Patterns a BIMS score of 14' indicated no cognitive impairment. Review of Resident #77's Comprehensive Care Plan initiated 01/22/2024, revealed: Focus: The resident has congestive heart failure. Goal: The resident will be free from complications related to CHF through the review date. Interventions: Monitor/document/report to MD PRN any s/sx of CHF: dependent edema of legs and feet .weight monitoring per physician's orders. Review of Resident #77's electronic physicians' orders revealed: Start date 01/19/2024, Discontinued 01/31/2024: Furosemide (Lasix) oral tablet 20 MG give 1 tablet every 24 hours as needed for swelling Start date 02/01/2024: 1500mL Fluid Restriction: Med Pass Fluids: Up to 600mL. Total AM: 240mL. Afternoon: 120mL. PM: 240mL. Meal Fluids: Up to 600mL. Total Breakfast: 120mL. Lunch: 240mL. Supper 240mL. Free Fluids: 300mL Start date 01/27/2024: Daily Weights Start date 02/02/2024: Edema Bilateral Legs: Monitor every Shift from increase edema or dressing rolling down. 1. Cleanse bilateral Les with dermal wound cleanser. 2. Apply Webril and Tubigrip D from base of toes to just below knees. 3. Change dressings PRN. Start date 01/31/2024: Torsemide Oral Table 20mg Give tablet by mouth two times a day. Review of Resident #77's Admit Evaluation, dated 01/19/2024 completed by RN D, revealed: 3+ edema (swelling) to bilateral lower extremities with discoloration. Review of Resident #77's electronic progress notes revealed: 01/19/2024 at 4:30pm signed by RN D: 3+ edema to bilateral lower extremities with discoloration. 01/20/2024 at 07:14 pm signed by RN E: +2 to +3 edema to BLE and Fluid restriction 1500 cc. 01/21/2024 at 03:47 am signed by RN F: the resident has mild pitting edema. 01/22/2024 at 04:53 pm signed by RN D: resident noted to have an increase in edema this shift to BLE. The resident has deep pitting, the indentation remains for a short time, looks swollen to. 01/23/2024 at 04:57 pm signed RN D: resident noted to have an increase in edema this shift to BLE; Resident requested to be laid in bed. Legs elevated. The resident has deep pitting, the indentation remains for a short time, looks swollen to. 01/24/2024 at 02:52 am signed by RN G: The resident has deep pitting, the indentation remains for a short time, looks swollen to. +2 to +3 edema to BLE; Fluid restriction 1500 cc. 01/25/2024 at 02:53 am signed by RN F: The resident has moderate pitting edema; indentation subsides rapidly to. Further review of electronic progress notes revealed no evidence of notifying the physician. 01/26/2024 at 03:07 pm signed by LVN H: The resident has moderate pitting edema; indentation subsides rapidly to. Resident continues to have increased edema to BLE. Continues to monitor resident for c/o pain to site, continue to provide PRN Lasix per orders for edema. Continue to encourage resident to elevate extremities. Resident dangles legs a majority of the day, unless resting in bed. Resident is aware of edema and our concerns. Lab results in review of physician at this time. Residents' family expresses concern about edema. Resident has history of diuretic secretion disorder. Nurse Practitioner in facility assessed resident this shift. Awaiting response. 01/26/2024 at 03:55 pm signed by LVN I: Edema present to BLE, 3+. Receives Lasix 20mg QD PRN for edema. Residents' family member expresses concern regarding edema and Lasix and would like to have Lasix scheduled daily. Nurse Practitioner aware of family members concerns and is reviewing. Placed on daily weights at this time x7 days. 01/26/24 at 4:27 PM signed by Nurse Practitioner: Resident #77 is lying in bed, alert, and smiling. She states that she does have some slight pain to her legs. Nursing staff reports edema to bilateral lower legs that causes the patient some discomfort with ROM and with transfers. Pitting Edema 3+ pitting edema noted to bilateral lower extremities. No s/sx of cellulitis noted at this time. Will advise to obtain daily weight X7 days and notify provider of >3 lb. wt. gain noted. Follow up in one week. 01/27/2024 at 01:33 pm signed by RN E: Upon daily assessment, resident's BLE noted at +4 edema to BLE with erythema and purple discoloration from feet to knees with erythema and edema moving up the inner and outer bilateral thighs. BLE warm and sensitive. Resident received new order for Lasix. Resident was to lay down with BLE elevated and Lasix administered. Will re-evaluate in 2-hours to re-assess for worsening erythema, warmth, and/or pain. Family member notified via phone with no questions or concerns at this time. 01/27/2024 at 05:57 pm signed by RN E: Resident's BLE re-assessed, and edema and purple discoloration improved and found to be erythematous, warm, and painful with erythema traveling up the inner and outer bilateral thighs. Physician notified and gave new order to send to ER to evaluate for possible cellulitis to the BLE. Resident is sitting up in bed, alert & oriented to baseline without confusion or distress at this time. Pain to BLE rated 4/10 and tender to touch. Family member notified via phone and requested resident be sent to hospital and will meet her there shortly. 01/28/2024 at 05:38 am signed by RN G: Resident returned from ER with new order for Clindamycin 300 mg TID for cellulitis and was initial dosed. Monitor edema. Daily weight. Monitor for s/sx of adverse reaction noted. Monitor for increased redness. Edema continues. Monitor weight No s/sx of adverse reaction noted. Redness continues. Edema continues to be + 3 Encouraged to elevate legs. Weight 206.4lbs 01/28/2024 at 06:28 pm signed by RN J: Resident came back from hospital this morning with new order of Clindamycin 300mg oral capsule TID due to cellulitis. Resident still has +3 Edema in both extremities. Encourage leg elevation to relieve edema. 01/29/2024 at 12:33 pm signed by LVN K: Resident continues to have increased edema to BLE. Continue to monitor resident for c/o pain to site, continue to provide PRN Lasix per orders for edema. Continue to encourage resident to elevate extremities. Resident dangles legs a majority of the day, unless resting in bed. Resident aware of edema and our concerns. Increasing edema to BLE. 01/29/2024 at 1:23 pm signed by LVN I: CHF clinic contacted regarding resident's edema to BLE. Continues with 3-4+ edema to BLE. Discoloration is present and resident is currently being treated for cellulitis with doxycycline. Resident does have mild discomfort when legs are palpated. Sits up in wheelchair most of day with legs extended with footrests per her choice. Current diuretic orders include Lasix 20mg QD PRN for edema. Significant weight gain is noted since admission r/t fluid. CHF clinic contacted to notify Provider and obtain recommendations. 01/30/2024 at 9:15 am signed by LVN I: CHF clinic contacted again to f/u on resident's edema. Spoke with office and informed them of edema to BLE and weight gain. Also requested all notes from previous visits. Office to notify provider and appointment scheduled for 1/31/24 @ 0930. 01/31/2024 at 11:47 am signed by LVN I: Resident attended appointment with CHF clinic today for f/u d/t BLE edema. Weight gain was noted by provider. 3-4+ edema present to BLE. Labs performed at appointment. Orders given by provider for the following: stop Lasix, start torsemide 20mg PO BID. Family member was present at appointment and aware. Review of Resident #77's electronic MAR revealed: 01/20/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/21/2024 at 10:23am Furosemide 20mg was administered 01/22/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/23/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/24/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/25/2024: order for Lasix and no evidence of administration 01/26/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/27/2024 at 11:06am: Furosemide 20mg was administered 01/28/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/29/2024 at 12:21 pm: Furosemide 20mg was administered 01/30/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration Review of ER Discharge note dated 01/28/2024 revealed discharged with antibiotic Clindamycin 300mg three times a day for cellulitis. Review of Resident #77's CHF Clinic Patient Summary, date 01/31/2024, revealed: The patient is seen today as emergent work-in appointment. Her weight is up 7 lbs. from the last appointment one week ago. She has 3 to 4+ edema to lower legs bilaterally with weeping from the legs. She was seen in trauma center for cellulitis and was started on antibiotics. She is in a wheelchair. The patient feels like Lasix is no longer effective in keeping her swelling controlled. The patient was given 40 milliequivalents of potassium. She was also given 80 milligrams of IV Lasix for her weight gain and heart failure symptoms. During an observation and interview on 01/29/24 at 12:13 PM, revealed Resident #77 sitting in recliner and resident family member sitting on her bed. Resident #77's legs were swollen, red, and not elevated. No signs or symptoms of respiratory or acute distress noted. Resident denied pain or any shortness of breath. Resident #77's family member stated Resident #77 had a history of problems with swelling and fluid overload. She stated Resident #77 was sent to the emergency room on [DATE] and was diagnosed with cellulitis (infection of the legs). During an observation and interview on 01/31/24 at 2:00 PM, Resident #77 was up in wheelchair just returning from her visit the CHF clinic No signs or symptoms of respiratory or acute distress noted. Resident denied pain or any shortness of breath. Resident stated she received liquid Lasix for her swelling and that she was going to pee all night. During an interview on 01/31/24 at 03:00 PM, the DON stated all residents with PRN Lasix orders should have also had an order for edema monitoring. She stated Lasix should have been given every day that Resident #77 had edema documented and the physician should have been notified each time. The DON stated not giving the Lasix could have caused the cellulitis and could have prevented the fluid overload and the need for IV Lasix. The DON stated it was a system failure that led to the Lasix not being administered as needed. She stated she was ultimately responsible for monitoring and ensuring that all physicians orders were followed. During an interview on 01/31/24 at 03:30 PM, LVN H stated she was aware that Resident #77 had PRN Lasix orders. She stated she did not give the Lasix because Resident #77 did not tolerate it well. She stated the Nurse Practitioner did not want the Lasix given. LVN H stated she had discussed the edema and Lasix order with the Nurse Practitioner but had not documented the conversation. Attempted interview with RN-D on 01/31/2024 at 1:31 pm via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-D on 02/14/2024 at 11:30 am via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-E on 01/31/2024 at 1:33pm via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-E on 02/14/2024 at 11:32 am via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-F on 01/31/2024 at 1:35pm via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-F on 02/14/2024 at 11:37 am via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-G on 01/31/2024 at 1:45pm via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-G on 02/14/2024 at 11:42 am via phone call with no answer. Voice mail left with no return call. Attempted interview with physician on 01/31/2024 at 3:50 PM via phone call with no answer. Voice mail left with no return call. Attempted interview with physician on 02/14/2024 at 11:12 AM via phone call with no answer. Voice mail left with no return call. During an interview on 01/31/24 at 04:00 PM, Resident #77's Nurse Practitioner stated she had seen Resident #77 on 01/26/24 and she had 3+ edema but no signs of cellulitis at that time. She stated she did not order Lasix to be routinely given because she was monitoring her prior labs. Nurse Practitioner stated she had not told any staff not to give the Lasix as needed per physicians' orders. She stated her expectation was for it to be given daily if needed and to be notified. She stated she had never been contacted or notified of Resident #77's edema other than on 01/26/2024 when she visited the facility. Nurse Practitioner stated not administering Lasix as needed could have led to the cellulitis and the fluid overload. During a follow up interview on 02/14/2024 at 12:10pm, Resident #77's Nurse Practitioner stated was concerned about routine Lasix bottoming out the resident's sodium and potassium levels. She stated that the risk of low sodium and potassium levels outweighed the resident's edema because the resident was not in acute distress nor had shortness of breath. The Nurse Practitioner stated that low sodium and potassium levels can lead to cardiac issues such as cardiac arrhythmias. The Nurse Practitioner also stated that the resident was an established patient with the local CHF clinic and when consulting with the resident's physician, the plan of care was to monitor and allow the CHF clinic to address the edema. She stated the facility was able to get the resident an earlier appointment. She stated again that the resident was never in acute distress nor had shortness of breath; therefore, she did not have a concern about the Furosemide being administered. During interview on 01/31/2024 at 8:00pm, DON and Administrator stated the facility did not have a policy for following physician's orders. Review of Center for Disease Control and Prevention website accessed on 02/15/2024 at https://www.cdc.gov/groupastrep/diseases-public/Cellulitis.html revealed: Cellulitis is a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin. Review of the Food and Drug Administration website accessed on 02/15/2024 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/016273s061lbl.pdf revealed: WARNING: Lasix (furosemide) is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion. Therefore, careful medical supervision is required, and dose and dose schedule must be adjusted to the individual patient's needs. Lasix is indicated in adults and pediatric patients for the treatment of edema associated with congestive heart failure. Review of the Food and Drug Administration website accessed on 02/15/2024 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020136s023lbl.pdf revealed: Demadex (torsemide) is a diuretic.