**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to notify the physician and the resident's responsible party for 1 (Resident #18) of 3 residents reviewed for resident rights. The facility failed to notify Resident #18's physician and RP that the resident did not receive 12 doses of Torsemide between 08/01/23 and 08/07/23 as ordered.) This failure resulted in the identification of Immediate Jeopardy (IJ) on 08/15/23 at 3.22 PM. While the immediacy was removed on 08/18/23 at 10:50 AM, the facility remained out of compliance with a severity of no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of complications from deterioration in health, worsening of conditions, extended recoveries, and hospitalizations. Findings included: Record review of Resident #18's admission record dated 08/15/23 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included, acute on chronic systolic (congestive) heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic respiratory failure with hypercapnia (result of mechanical defects, central nervous system depression, imbalance of energy demands and supplies and/or adaptation of central controllers), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and diabetes (a group of diseases that result in too much sugar in the blood). Record review of Resident #18's quarterly MDS assessment, dated 06/08/23, revealed a BIMS of 15, which indicated she was cognitively intact. Resident #18 required supervision and one-person physical assistance with bed mobility and eating, and extensive assist with one-person physical assistance for transfers, dressing, toilet use, and personal hygiene. Record review of Resident #1's Nursing Progress Note, dated 08/07/23 at 13:36 (1:36 PM) by the ADON revealed the following: While assessing resident this morning, resident stated she had not received her torsemide since last Tuesday. Upon looking into her medication administration, I noticed the med had been ordered but had not been delivered. I contacted Pharmacy and they stated it would not be refillable until 8/11 and I stated she needed it now since she had already been without it. Pharmacy information was incorrect in regard to her order. They were showing it was to be given once a day and our order shows twice a day. I faxed them the order and they stated they would send out today. I requested her weight, and it reflected a gain of 14 pounds since Friday, August 4th. On-call was paged. Doctor on-call asked to give IM of Lasix, but resident refused and requested to go to [NAME] and [NAME] so they could take the fluid off quickly. Son was on phone with her at the time and was requesting she be sent out as well. Vital signs WNL: Bp 134/62,T 97.7, P 62, Resp 20. Resident was not having any signs of distress and denied having any pain. Weight on Friday was 314 and today was 328. On-call doctor was made aware she was sent out and [family member], was contacted as well. Record Review of Resident #18's progress notes revealed facility did not contact MD or on call doctors during time between 08/01/23 and 08/07/23 in regard to missing diuretic medication. MD was contacted in regard to another issue but still was not informed of missing medication. Record review of Resident #18's physician orders dated 08/15/23 revealed Torsemide Oral Tablet 20 mg give 4 tablets by mouth two times a day. Record review of Resident #18's MAR for June 2023 revealed Torsemide 100 mg by mouth two times a day was ordered from 07/23/23 to 08/10/2023 and changed to Torsemide 20 mg give 4 tablets by mouth two times daily on 08/10/23. Record review of Resident #18's MAR for June 2023 revealed Torsemide 100 mg by mouth two times a day was given on 08/01/23 as ordered and the 8:00 AM dose on 08/02/23 and the 13:00 (1:00 pm) dose of Torsemide 100 mg by mouth two times a day was not given from 08/02/23 to 08/07/23 when medication error was discovered at 13:36 (1:36 pm) by the ADON. Torsemide 100 mg 1 tablet by mouth two times a day. This medication can treat fluid retention(edema) caused by congestive heart failure, kidney disease, or liver disease. It can also treat high blood pressure alone or in combination with other medications per Google. Record review of residents care plan dated 08/15/23 revealed: Resident #18 has renal insufficiency r/t chronic severe stage 4 kidney disease. Goals: I will be free from infection through the review date, I will have no s/s of complications r/t fluid deficit through the review date., and I will be able to resume normal daily activities of daily living through the review date. Interventions: Monitor/document/report for s/sx of acute renal failure: Oliguria (urine output <400ml per 24 hr.); Increased BUN and Creatinine; In the Diuretic phase, (output >500 ml/24 hr) the BUN and Creatinine level out, and Monitor/document/report to MD PRN the following s/sx: Edema; weight gain of over 2 lbs a day; neck vein distension; difficulty breathing (Dyspnea); increased heart rate (Tachycardia); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness ; Monitor breath sounds for crackles. During an interview on 08/15/23 at 2:27 PM with Resident #18, she stated she received her last dose of diuretic medication on the morning of August 1st, 2023, and she had not received or refused it since. She stated she did not refuse the medication at all during the time of the last dose of medication and until the problem was discovered as to why her medication was not being delivered to the facility by the pharmacy, which was Monday, August 7th. She stated she went to the hospital on that day because she had gained 14 pounds over the weekend. She stated she received a huge dose of IV Lasix and she immediately lost 7 pounds. She stated she had received the medication since she returned to the facility from the emergency room with no problems. She stated she had refused the diuretic medication at times due to it causing her to urinate so much during the day and night and it kept her up at night. She stated she communicated with her doctor regarding the diuretic medication and the doctor made changes as needed. During an interview on 08/15/23 at 10:05 AM with the ADON, she stated if a resident was out of a medication that was ordered to be given, staff should have ordered the medication immediately, called the physician, and called the pharmacy and found out why the medication had not been sent. She stated the pharmacy could also call another local pharmacy to supply the medication if needed. She stated the staff should also have checked the E-kit to ensure residents did not miss any doses of medication. She stated there are possible risks involved if a resident missed doses of a medication, such as a high blood pressure medication missed could have caused a residents blood pressure to go up. She stated if medications were missed for a long period of time, it could possibly have caused harm to a resident. She stated she considered a couple of days a long period of time and that if a resident had an order for a medication to be given daily, it should have been given as ordered. She stated if the medication missed was a diuretic medication, it could cause fluid to build up on a resident. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, the medication aide had told the nurse that the resident was out of the medication. She stated the nurse called the pharmacy, and the pharmacy told the nurse the medication had been ordered. She stated when the medications were delivered that night to the facility, the medication still did not come in. She stated the next day the medication aide asked the nurse to get the medication out of the E-kit and when the nurse went to get the medication, there was none of that kind of medication in the E-kit. She stated the nurse called the pharmacy again and the pharmacy told the nurse again they were sorry they didn't send the medication and they would send it that night. She stated that Monday, she had worked the floor and had took care of Resident #18. She stated Resident #18 told her that she hadn't gotten her diuretic in a few days. She stated she told Resident #18 that she was going to check into it and that is when she found out the medication was not in the facility. She stated she called the pharmacy, and they told her it was on order, and she told them the facility had been getting told that. She stated the pharmacy then told her the medication was not fillable until the 11th. She stated she told the pharmacy the medication was needed then, and resident had been out and had not received it in 4 days. She stated pharmacy told her the order they had an order that the medication was to be given once a day and the order the facility had was for resident to get the medication twice a day and that is why it was not able to be filled. She stated she had already paged the on-call doctor to inform of incident, she faxed the correct order to the pharmacy and called to ensure the order was received and the medication would be sent that day. She stated she was not sure why the pharmacy did not update the order when the order was changed because the pharmacy pulled it straight from the system in which the facility put orders in. She stated she had staff weigh Resident #18 and Resident #18 had gained 14 pounds from Friday to Monday. She stated the on-call doctor called her back and she informed doctor of the incident. She stated the doctor ordered an IM injection of Lasix (another diuretic medication), but Resident #18 refused the medication and requested to be sent to the emergency room for the hospital to give her the medication IV. She stated she notified the doctor that Resident #18 refused the medication and wanted to be sent to the hospital and the resident's family wanted Resident #18 to go to the emergency room as well. She stated the doctor gave orders for Resident #18 to be sent to the hospital and she arranged transportation for Resident #18 to be transported to hospital. She stated Resident #18 went to hospital and returned the same evening. She stated the hospital had given Resident #18 80 mg of Lasix IV and had gotten 2 liters of fluid off of Resident #18. She stated Resident #18 was very non-complaint with her diet and asked for things such as bacon, even though she was on a low sodium diet. She stated Resident #18's family brought her pizzas and things that were not on Resident #18's diet as well and she did not think all that weight was just from fluid buildup. She stated she was not sure of what Resident #18's weight was upon return from hospital. She stated Resident #18's routinely ordered medication, did come in from the pharmacy that day and Resident #18 had been on her routinely scheduled medication since returning from the hospital with no interruption due to medication not being in facility. She stated Resident #18 had a history of refusing medications and had refused the diuretic medication about 2 or 3 times since returned from emergency room visit. She stated Resident #18 said she refused the medication at times because she did not want to urinate so much. She stated she in-serviced staff on reordering medications and medication errors. She stated the staff were also in-serviced on the 8 rights of medications and medication administration. She stated if staff were checking the medication card with the medication order in the system the error may not have occurred because it would have been noticed earlier. She stated anytime a resident was out of their medication, the staff should be ordering a week prior to the resident running out of the medication. She stated if it was not received, they should inform the nurse. She stated the nurse should follow up with the pharmacy and find out if there was an issue with the medication and what needs to be done to ensure a resident did not miss any doses. She stated the nurse should also inform management for follow up and if there were any issues. During an interview on 08/15/23 at 10:48 AM with the DON, she stated if a resident was out of a medication that was ordered to be given, staff should call the pharmacy to see if medication can be expedited over, and if not, they should contact a local pharmacy where medication could be picked up. She stated if an ordered medication was missed, lab values could be affected or fluid levels could fluctuate, or mood could be affected, it just depended on the medication. She stated if the medication missed was a diuretic medication, it could possibly cause fluid level to fluctuate, swelling or edema, and respiratory distress. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, the medication was not in the facility. She stated the pharmacy had been reached out to a few times and told the facility the medication was being sent those days, but medication was not received. She stated the staff were in-serviced on if they contacted the pharmacy and still didn't receive the medications, they should notify the ADONs and herself and they can call the pharmacy and find the issue and get it fixed so that resident doesn't miss any medication. She stated if they cannot get the medication that day, the staff should call the physician to get a hold order for that medication until medication can be provided, or to get a substitution until medication can be provided. She stated Resident #18 had a history of refusing the medication on some days due to going out on pass because Resident #18 did not want to urinate a lot. She stated she in-serviced staff on reordering medications and medication errors, the 8 rights of medications and medication administration. She stated she also did 1 on 1 in-servicing as needed with staff if there was disciplinary action needed or check off's with staff. She stated, medication aides should notify the nurse immediately and nurses should contact the pharmacy right away and notify the ADONs anytime a resident was out of their medication. During an interview on 08/15/23 at 12:03 PM with the MD, she stated if a resident missed one dose of a medication, it could potentially cause harm, depending on the medication. She stated if a resident missed multiple doses of a diuretic specifically, depending on residents clinical standpoint, if it was a onetime dose, it may not cause any harm, but if it was multiple doses, it could potentially cause fluid overload, and that could cause symptoms such as shortness of breath, pain if there is a significant amount of edema, and heart or kidney failure exacerbation if resident was diagnosed with heart or kidney failure. She stated it is very individualized for each person, so the potential outcomes vary. She stated the medical team was made aware of the incident regarding Resident #18, and they were informed as soon as the facility realized Resident #18 did not have the medication available. She stated the medical team gave a dose of medication as an alternative, but Resident #18 declined and wanted to go to the emergency room at that time. During an interview on 08/15/23 at 12:22 PM with the ADM and DON, they stated they had not had any QAPI meetings since 07/28/2023 and they did not discuss any concerns with medications during that meeting. They stated they had a policy that was in place for receiving medications and ensuring residents do not go without their medications. They stated the failure in the incident with Resident #18 not having medication in the facility, was a failure to follow policy; not that there was not a policy developed. During an interview on 08/15/23 at 2:46 PM with the DON, she stated Resident #18 refused the diuretic on 08/04/23 due to going out on pass with family. She stated it was documented on the MAR by the medication aide that the medication was not given on the 4th of August, but the medication aide had put NA for the reason why. She stated this medication aide was educated on not documenting NA but to document a description of what happened. She stated the nurse working that day later went in and documented that the resident refused the medication that day due to going out on pass. She stated she believed Resident #18 was not offered the medication when she refused it, but that Resident #18 told staff earlier in the day that she did not want her diuretic medication because she was going out on pass with family, and she did not want to be urinating the whole time. During an interview on 08/15/23 at 4:47 PM with ADON, she stated she does not believe Resident#18's doctor was notified during the time Resident #18 was missing her medication. She stated she believes the doctor was not notified until she did on 08/07/23. She stated staff should have notified the doctor as soon as the Resident #18 missed the first dose. During an interview on 08/15/23 at 4:49 PM with ADM, she stated she is not aware if Resident #18's doctor was notified during the time when Resident #18 was missing her diuretic medication. During an interview on 08/15/23 at 4:52 PM with DON, she stated she had nothing to show that staff informed the doctor of Resident #18's diuretic medication being missed. She stated she knew the staff notified the doctor about another issue going on with Resident #18, but not concerning the missed medication. During an interview on 08/15/23 at 4:56 PM with LVN B, he stated medications should be administered as ordered by physician. He stated he administered medication as a part of his job description. He stated if a resident was out of a medication that was ordered to be given, he would look for the medication, contact the pharmacy to find out what is going on, and if there were missed doses, he would contact the on-call doctor and notify them as well. He stated he would try to find out how long the resident had been out of the medication and why it was not brought to anyone's attention in a timely manner. He stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. He stated if the medication missed was a diuretic medication, it could cause harm in the long run, and depending on how long, it could cause acute problems such as swelling and shortness of breath as well. He stated he was in-serviced on 08/10/23 on reordering medications and medication errors. He stated the in-services covered the steps on what to take on missed medications. During an interview on 08/15/23 at 5:07 PM with LVN C, she stated medications should be administered as ordered by physician. She stated she administered medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given or missed doses of a medication, she would look into the E-kit to see if the med was available and contact the pharmacy to see if she could get an order sent STAT. She stated if a resident missed doses, she would report it to the ADON and DON so they could follow up on it. She stated she would also inform the physician if a resident missed doses of a medication. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated there is a reason why medication is prescribed. She stated if the medication missed was a diuretic medication, it could cause urinary retention, increased edema, and it could affect the heart in a negative way. She stated she was in-serviced on 08/10/23 on reordering medications and medication errors, and contacting the provider, ADON, Administrator, and family to inform them if resident missed a dose of medications. During an interview on 08/15/23 at 5:24 PM, MA D stated medications should be administered as ordered by physician. She stated she administered medication is a part of her job description. She stated if a resident was out of a medication that was ordered to be given, she would inform her nurse. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated if the medication missed was a diuretic medication, it could cause weight gain or it could affect the heart. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, she let her nurse know that the medication was missing, and she was told by the nurse that the medication was not in the E-kit. She stated she documented it each day the medication was not given. She stated she was in-serviced on 08/10/23 on reordering medications and medication errors, abuse and neglect and resident rights. She stated she will now let the nurse know the next steps that need to be done if they did not know and she would also inform the DON anytime a resident is out of their medication. During an interview on 08/15/23 at 5:35 PM with LVN A, she stated she administered medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given, she would check to see if it is in the E-kit to be given and order it from the pharmacy as well. She stated if a resident actually missed doses of a medication, she would contact the pharmacy and she would inform whoever is on-call and the doctor. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated if the medication missed was a diuretic medication, it could cause shortness of breath and increased edema. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of an ordered diuretic medication, she worked the weekend of the 4th, 5th, and 6th of August 2023. She stated on the 4th she was told Resident #18 refused the diuretic medication because resident was going out on pass that day, which was normal for Resident #18 to do. She stated on Saturday, the 5th, her medication aide told her that Resident #18 did not have the medication. She stated the medication was not in their E-kit and it was not carried in the E-kit here in the facility. She stated she then ordered the medication to be delivered that evening. She stated on Sunday, the following day, the medication aide informed her the medication had not came in on the previous day when she ordered it and so she looked into the system, and it showed the medication had been ordered. She stated she did not call the physician regarding Resident #18 missing the diuretic medication. She stated Resident #18 did not voice any concerns or complaints to her and it was her understanding that the medication would be delivered that Saturday, and that was why she didn't inform the physician about Resident #18 missing doses of the medication. She stated she did not call the pharmacy again on that Sunday because it was to her understanding that the pharmacy did not deliver medications on Sundays. She stated she was in-serviced on reordering medications and medication errors on 08/10/23. She stated the in-services covered missed doses of medication and explained what to do in the future and how to handle it if a resident missed a dose of medications. She stated she would call the emergency pharmacy number and see if the medication could be delivered and if medication was still unavailable, she would contact the physician and see what the physician wanted her to do and follow those orders anytime a resident was out of their medication. During an interview on 08/15/23 at 5:53 PM with the ADM, she stated medications should be administered to residents as ordered by physician. She stated she did not administer medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given or missed doses of medication, staff should contact the charge nurse and DON, contact the pharmacy to order the medication, and contact the medical director to inform of the situation. She stated if a medication is missed there is a risk for potential harm. She stated if the medication missed was a diuretic medication, it could cause possible heart issues if a resident had a diagnosis of congestive heart failure. She stated regarding the incident involving Resident #18 , where resident missed 12 doses of ordered diuretic medication, the missed medication was discovered, and she was informed. She stated she alerted her chief officer of operations of the facility, Resident #18's responsible party, and HHSC. She stated the Medical Director was notified upon discovery of missed medications. She stated the nurse should have notified the doctor with the first dose of medication. She stated she in-serviced staff on reordering medications and medication errors. She stated the in-services covered missing medications and what to do in the case of a resident missing a medication. She stated staff should now be notifying the medical director and following orders, notifying the pharmacy and using the emergency protocol to get the medication here to the facility STAT anytime a resident is out of their medication. 08/15/23 Record review of facility policy titled Administering Medications - Oral which was undated revealed: To ensure that medications are administered within the restrictions of employee licensure and per regulation and best practice in the industry. Procedure: Administering Oral Medications: General guidelines and precautions: 5. Follow the six rights of medication administration. - Right patient, right drug, right dose, right route, right time, right documentation. 6. Read the label 3 times as you prepare medication, carefully checking the drug label against the medication administration record (MAR), med card or physicians orders, according to facility policy: check #1 as you take the medicine from the storage area, check #2 as you pour the medicine, check #3: for multi-dose drugs - as you replace the label container into storage area. For unit-dose drugs - at the bedside, before opening the unit-dose medicine package.7. If a medication is unavailable or missing, notify the charge nurse. a. unavailable medication: charge nurse will check the E-kit to see if the dose is available. If not in the E-kit, the charge nurse will reach out to the facility pharmacy to initiate emergency refill if the cutoff time has already passed for the next scheduled delivery. b. Missing medication: charge nurse will begin search for missing medication. If the medication cannot be located, the charge nurse will notify the Director of Nursing and facility administration to initiate an investigation and proceed with the steps listed under bullet point a above. Assessments (Activities to be completed prior to preparing medications) 1. Check medication card or MAR against physician's orders medication Kardex, according to facility policy. 2. Check for the six rights. 4. Review resident data and observe and assess residents as an on-going basis to determine therapeutic effects, side effects, drug allergies, contraindications, and nursing implications. Administration: 11. Give ordered medication(s) to resident by cup or gently place medicine in residents mouth if indicated. (Follow the six rights). Policy has no clear guidance on physician notification regarding missed medication doses. 08/15/23 Record review of facility policy titled: Receiving medications from the pharmacy which is undated revealed: It is the policy of this facility to assure all medications are correctly delivered and errors rectified as soon as possible, to assure proper handling of all medications and to assure a system is adhered to at all times. On 08/15/23 at 3:22 PM, an Immediate Jeopardy (IJ) was identified. The ADM and DON was notified on 08/15/23 at 6:57 PM. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. 08/17/23 Record review of facility plan of removal for pharmacy services revealed: Facility Policy on and Notifications to Physicians, Family, and others - In-services on the topic Notification to Physician, Family and Others began on 8/16/23 and were completed with current nursing staff on 8/16/23 by the DON and nurse educators. The RN, LVN, and Medication Aides were taught that the facility will inform the resident; consult with resident's physician; medical director, and notify, consistent with his or her authority, the resident representative and document in the resident's medical record. The nurses and medication aides currently on shift will pass a post-test of 5 questions pertaining to the Notification to Physician, Family and Others policy to demonstrate competency/understanding and a required grade of 100%. If they fail they will be immediately reeducated and required to retake the post-test and achieve 100%. The RN, LVN, and Medication Aides not currently on shift will be in-serviced before taking any assignment in the facility by 8/17/2023. The nurse educators will be in-serviced by the Director of Nursing on the notifying the medical provider and medical; director on 8/16/2023, and then the DON/RN, and both ADON's will educate the nursing staff on 8/16/2023-8/17/2023. Nurses and Medication Aides will receive training on the same topics during new employee orientation. The DON, ADON, and Administrator performed an audit from the 24-hour report on 8/08/2023 to ensure no other residents had missing or unavailable medication, and there were no other discrepancies. All remaining Nurses and Medication Aides not present will be required to be in-service on the above topics and pass the post-test for prior taking any assignment in the facility. A Quality Assurance Performance Improvement meeting was held on 8/16/2023 to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified on 8/15/23 of the Immediate Jeopardy For the next 30 days, the Director of Nursing will monitor three (3) nurses per week on the listed educational topics and the post-test given to determine retention of knowledge. Should one of the nurses fail the post-test immediate re-education will be provided and the post-test administered again until a 100% score is achieved. For the next 30 days, the Director of Nursing will monitor three (1) medication aide per week on Administering Medication and the post-test given to determine retention of knowledge. Should one of the Medication Aides fail the post-test immediate re-education will be provided and the post-test administered again until a 100% score is achieved. The Director of Nursing and the Administrator will review the 24-hour report Monday-Friday and the weekend report will be reviewed on Monday, promulgated by Point Click Care to review any medications listed as not given, NA, or medication on order and will follow-up immediately with the pharmacy and/or physician or other mid-level practitioner assigned to the residents care to ensure appropriate follow through. The following was monitoring of the facility's corrective actions between 08/16/23 and 8/18/23: During an interview on 08/16/23 at 9:03 AM with the MD, she stated if she was made aware that Resident #18 was missing doses of medication, she would have substituted the medication for something else or arranged for the medication to be picked up by family or staff at a local pharmacy. She stated she was not made aware of the medication not being administered until 08/07/23. During an interview on 08/16/2023 at 1:32 PM with MA E, she stated she was in-serviced on 08/16/23 regarding policy for passing medications correctly and it incorporated who to notify in different instances. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would notify her charge nurse. She stated it was true that if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would notify the Administrator. She stated anytime a resident missed a dose of medication, she would [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #18) reviewed for pharmacy services. The facility failed to ensure Resident #18 received 12 doses (08/01/23 to 08/07/23) of Torsemide (for the treatment of fluid retention (edema) caused by congestive heart failure, kidney disease, or liver disease due to its unavailability in facility. This failure resulted in the identification of Immediate Jeopardy (IJ) on 08/15/23 at 3.22 PM. While the immediacy was removed on 08/18/23 at 10:50 AM, the facility remained out of compliance with a severity of no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of complications from deterioration in health, worsening of conditions, extended recoveries, and hospitalizations. Findings included: Record review of Resident #18's admission record dated 08/15/23 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included, acute on chronic systolic (congestive) heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic respiratory failure with hypercapnia (result of mechanical defects, central nervous system depression, imbalance of energy demands and supplies and/or adaptation of central controllers ), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and diabetes (a group of diseases that result in too much sugar in the blood). Record review of Resident #18's quarterly MDS assessment, dated 06/08/23, revealed a BIMS of 15, which indicated she was cognitively intact. Resident #18 required supervision and one-person physical assistance with bed mobility and eating, and extensive assist with one-person physical assistancefor transfers, dressing, toilet use, and personal hygiene. Record review of residents care plan dated 08/15/23 revealed: Resident #18 has renal insufficiency r/t chronic severe stage 4 kidney disease. Goals: I will be free from infection through the review date, I will have no s/s of complications r/t fluid deficit through the review date., and I will be able to resume normal daily activities of daily living through the review date. Interventions: Monitor/document/report for s/sx of acute renal failure: Oliguria (urine output <400ml per 24 hr.); Increased BUN and Creatinine; In the Diuretic phase, (output >500 ml/24 hr) the BUN and Creatinine level out, and Monitor/document/report to MD PRN the following s/sx: Edema; weight gain of over 2 lbs a day; neck vein distension; difficulty breathing (Dyspnea); increased heart rate (Tachycardia); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness ; Monitor breath sounds for crackles. Record review of Resident #18's physician orders dated 08/15/23 revealed Torsemide Oral Tablet 20 mg give 4 tablets by mouth two times a day. Record review of Resident #18's MAR for June 2023 revealed Torsemide 100 mg by mouth two times a day was ordered from 07/23/23 to 08/10/2023 and changed to Torsemide 20 mg give 4 tablets by mouth two times daily on 08/10/23 Record review of Resident #18's MAR for June 2023 revealed Torsemide 100 mg by mouth two times a day was given on 08/01/23 as ordered and the 8:00 AM dose on 08/02/23 and the 13:00 (1:00 pm) dose of Torsemide 100 mg by mouth two times a day was not given from 08/02/23 to 08/07/23 when medication error was discovered at 13:36 (1:36 pm) by the ADON. Record review of Resident #1's Nursing Progress Note , dated 08/07/23 at 13:36 (1:36 PM) by the ADON revealed the following: While assessing resident this morning, resident stated she had not received her torsemide since last Tuesday. Upon looking into her medication administration, I noticed the med had been ordered but had not been delivered. I contacted Pharmacy and they stated it would not be refillable until 8/11 and I stated she needed it now since she had already been without it. Pharmacy information was incorrect in regard to her order. They were showing it was to be given once a day and our order shows twice a day. I faxed them the order and they stated they would send out today. I requested her weight, and it reflected a gain of 14 pounds since Friday, August 4th. On-call was paged. Doctor on-call asked to give IM of Lasix, but resident refused and requested to go to [NAME] and [NAME] so they could take the fluid off quickly. Son was on phone with her at the time and was requesting she be sent out as well. Vital signs WNL: Bp 134/62,T 97.7, P 62, Resp 20. Resident was not having any signs of distress and denied having any pain. Weight on Friday was 314 and today was 328. On-call doctor was made aware she was sent out and family member , was contacted as well. During an interview on 08/15/23 at 2:27 PM with Resident #18, she stated she received her last dose of diuretic medication on the morning of August 1st, 2023, and she had not received or refused it since. She stated she did not refuse the medication at all during the time of the last dose of medication and until the problem was discovered as to why her medication was not being delivered to the facility by the pharmacy, which was Monday, August 7th. She stated she went to the hospital on that day because she had gained 14 pounds over the weekend. She stated she received a huge dose of IV Lasix and she immediately lost 7 pounds. She stated she had received the medication since she returned to the facility from the emergency room with no problems. She stated she had refused the diuretic medication at times due to it causing her to urinate so much during the day and night and it kept her up at night. She stated she communicated with her doctor regarding the diuretic medication and the doctor made changes as needed. During an interview on 08/15/23 at 10:05 AM with the ADON , she stated if a resident was out of a medication that was ordered to be given, staff should have ordered the medication immediately, called the physician, and called the pharmacy and found out why the medication had not been sent. She stated the pharmacy could also call another local pharmacy to supply the medication if needed. She stated the staff should also have checked the E-kit to ensure residents did not miss any doses of medication. She stated there are possible risks involved if a resident missed doses of a medication, such as a high blood pressure medication missed could have caused a residents blood pressure to go up. She stated if medications were missed for a long period of time, it could possibly have caused harm to a resident. She stated she considered a couple of days a long period of time and that if a resident had an order for a medication to be given daily, it should have been given as ordered. She stated if the medication missed was a diuretic medication, it could cause fluid to build up on a resident. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, the medication aide had told the nurse that the resident was out of the medication. She stated the nurse called the pharmacy, and the pharmacy told the nurse the medication had been ordered. She stated when the medications were delivered that night to the facility, the medication still did not come in. She stated the next day the medication aide asked the nurse to get the medication out of the E-kit and when the nurse went to get the medication, there was none of that kind of medication in the E-kit. She stated the nurse called the pharmacy again and the pharmacy told the nurse again they were sorry they didn't send the medication and they would send it that night. She stated that Monday, she had worked the floor and had took care of Resident #18. She stated Resident #18 told her that she hadn't gotten her diuretic in a few days. She stated she told Resident #18 that she was going to check into it and that is when she found out the medication was not in the facility. She stated she called the pharmacy, and they told her it was on order, and she told them the facility had been getting told that. She stated the pharmacy then told her the medication was not fillable until the 11th. She stated she told the pharmacy the medication was needed then, and resident had been out and had not received it in 4 days. She stated pharmacy told her the order they had an order that the medication was to be given once a day and the order the facility had was for resident to get the medication twice a day and that is why it was not able to be filled. She stated she had already paged the on-call doctor to inform of incident. She faxed the correct order to the pharmacy and called to ensure the order was received and the medication would be sent that day. She stated she was not sure why the pharmacy did not update the order when the order was changed because the pharmacy pulled it straight from the system in which the facility put orders in. She stated she had staff weigh Resident #18 and Resident #18 had gained 14 pounds from Friday to Monday. She stated the on-call doctor called her back and she informed doctor of the incident. She stated the doctor ordered an IM injection of Lasix (another diuretic medication), but Resident #18 refused the medication and requested to be sent to the emergency room for the hospital to give her the medication IV. She stated she notified the doctor that Resident #18 refused the medication and wanted to be sent to the hospital and the resident's family wanted Resident #18 to go to the emergency room as well. She stated the doctor gave orders for Resident #18 to be sent to the hospital and she arranged transportation for Resident #18 to be transported to hospital. She stated Resident #18 went to hospital and returned the same evening. She stated the hospital had given Resident #18 80 mg of Lasix IV and had gotten 2 liters of fluid off of Resident #18. She stated Resident #18 was very non-complaint with her diet and asked for things such as bacon, even though she was on a low sodium diet. She stated Resident #18's family brought her pizzas and things that were not on Resident #18's diet as well and she did not think all that weight was just from fluid buildup. She stated she was not sure of what Resident #18's weight was upon return from hospital. She stated Resident #18's routinely ordered medication, did come in from the pharmacy that day and Resident #18 had been on her routinely scheduled medication since returning from the hospital with no interruption due to medication not being in facility. She stated Resident #18 had a history of refusing medications and had refused the diuretic medication about 2 or 3 times since returned from emergency room visit. She stated Resident #18 said she refused the medication at times because she did not want to urinate so much. She stated she in-serviced staff on reordering medications and medication errors. She stated the staff were also in-serviced on the 8 rights of medications and medication administration. She stated if staff were checking the medication card with the medication order in the system the error may not have occurred because it would have been noticed earlier. She stated anytime a resident was out of their medication, the staff should be ordering a week prior to the resident running out of the medication. She stated if it was not received, they should inform the nurse. She stated the nurse should follow up with the pharmacy and find out if there was an issue with the medication and what needs to be done to ensure a resident did not miss any doses. She stated the nurse should also inform management for follow up and if there were any issues. During an interview on 08/15/23 at 10:48 AM with the DON, she stated if a resident was out of a medication that was ordered to be given, staff should call the pharmacy to see if medication can be expedited over, and if not, they should contact a local pharmacy where medication could be picked up. She stated if an ordered medication was missed, lab values could be affected or fluid levels could fluctuate, or mood could be affected, it just depended on the medication. She stated if the medication missed was a diuretic medication, it could possibly cause fluid level to fluctuate, swelling or edema, and respiratory distress. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, the medication was not in the facility. She stated the pharmacy had been reached out to a few times and told the facility the medication was being sent those days, but medication was not received. She stated the staff were in-serviced on if they contacted the pharmacy and still didn't receive the medications, they should notify the ADONs and herself and they can call the pharmacy and find the issue and get it fixed so that resident doesn't miss any medication. She stated if they cannot get the medication that day, the staff should call the physician to get a hold order for that medication until medication can be provided, or to get a substitution until medication can be provided. She stated Resident #18 had a history of refusing the medication on some days due to going out on pass because Resident #18 did not want to urinate a lot. She stated she in-serviced staff on reordering medications and medication errors, the 8 rights of medications and medication administration. She stated she also did 1 on 1 in-servicing as needed with staff if there was disciplinary action needed or check off's with staff. She stated, medication aides should notify the nurse immediately and nurses should contact the pharmacy right away and notify the ADONs anytime a resident was out of their medication. During an interview on 08/15/23 at 12:03 PM with the MD, she stated if a resident missed one dose of a medication, it could potentially cause harm, depending on the medication. She stated if a resident missed multiple doses of a diuretic specifically, depending on residents clinical standpoint, if it was a onetime dose, it may not cause any harm, but if it was multiple doses, it could potentially cause fluid overload, and that could cause symptoms such as shortness of breath, pain if there is a significant amount of edema, and heart or kidney failure exacerbation if resident was diagnosed with heart or kidney failure. She stated it is very individualized for each person, so the potential outcomes vary. She stated the medical team was made aware of the incident regarding Resident #18, and they were informed as soon as the facility realized Resident #18 did not have the medication available. She stated the medical team gave a dose of medication as an alternative, but Resident #18 declined and wanted to go to the emergency room at that time. During an interview on 08/15/23 at 12:22 PM with the ADM and DON, they stated they had not had any QAPI meetings since 07/28/2023 and they did not discuss any concerns with medications during that meeting. They stated they had a policy that was in place for receiving medications and ensuring residents do not go without their medications. They stated the failure in the incident with Resident #18 not having medication in the facility, was a failure to follow policy; not that there was not a policy developed. During an interview on 08/15/23 at 2:46 PM with the DON, she stated Resident #18 refused the diuretic on 08/04/23 due to going out on pass with family. She stated it was documented on the MAR by the medication aide that the medication was not given on the 4th of August, but the medication aide had put NA for the reason why. She stated this medication aide was educated on not documenting NA but to document a description of what happened. She stated the nurse working that day later went in and documented that the resident refused the medication that day due to going out on pass. She stated she believed Resident #18 was not offered the medication when she refused it, but that Resident #18 told staff earlier in the day that she did not want her diuretic medication because she was going out on pass with family, and she did not want to be urinating the whole time. During an interview on 08/15/23 at 4:56 PM with LVN B, he stated medications should be administered as ordered by physician. He stated he administered medication as a part of his job description. He stated if a resident was out of a medication that was ordered to be given, he would look for the medication, contact the pharmacy to find out what is going on, and if there were missed doses, he would contact the on-call doctor and notify them as well. He stated he would try to find out how long the resident had been out of the medication and why it was not brought to anyone's attention in a timely manner. He stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. He stated if the medication missed was a diuretic medication, it could cause harm in the long run, and depending on how long, it could cause acute problems such as swelling and shortness of breath as well. He stated he was in-serviced on 08/10/23 on reordering medications and medication errors. He stated the in-services covered the steps on what to take on missed medications. During an interview on 08/15/23 at 5:07 PM with LVN C, she stated medications should be administered as ordered by physician. She stated she administered medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given or missed doses of a medication, she would look into the E-kit to see if the med was available and contact the pharmacy to see if she could get an order sent STAT. She stated if a resident missed doses, she would report it to the ADON and DON so they could follow up on it. She stated she would also inform the physician if a resident missed doses of a medication. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated there is a reason why medication is prescribed. She stated if the medication missed was a diuretic medication, it could cause urinary retention, increased edema, and it could affect the heart in a negative way. She stated she was in-serviced on 08/10/23 on reordering medications and medication errors, and contacting the provider, ADON, Administrator, and family to inform them if resident missed a dose of medications. During an interview on 08/15/23 at 5:24 PM,MD stated medications should be administered as ordered by physician. She stated she administered medication is a part of her job description. She stated if a resident was out of a medication that was ordered to be given, she would inform her nurse. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated if the medication missed was a diuretic medication, it could cause weight gain or it could affect the heart. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, she let her nurse know that the medication was missing, and she was told by the nurse that the medication was not in the E-kit. She stated she documented it each day the medication was not given. She stated she was in-serviced on 08/10/23 on reordering medications and medication errors, abuse and neglect and resident rights. She stated she will now let the nurse know the next steps that need to be done if they did not know and she would also inform the DON anytime a resident is out of their medication. During an interview on 08/15/23 at 5:35 PM with LVN A, she stated she administered medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given, she would check to see if it is in the E-kit to be given and order it from the pharmacy as well. She stated if a resident actually missed doses of a medication, she would contact the pharmacy and she would inform whoever is on-call and the doctor. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated if the medication missed was a diuretic medication, it could cause shortness of breath and increased edema. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of an ordered diuretic medication, she worked the weekend of the 4th, 5th, and 6th of August 2023. She stated on the 4th she was told Resident #18 refused the diuretic medication because resident was going out on pass that day, which was normal for Resident #18 to do. She stated on Saturday, the 5th, her medication aide told her that Resident #18 did not have the medication. She stated the medication was not in their E-kit and it was not carried in the E-kit here in the facility. She stated she then ordered the medication to be delivered that evening. She stated on Sunday, the following day, the medication aide informed her the medication had not came in on the previous day when she ordered it and so she looked into the system, and it showed the medication had been ordered. She stated she did not call the physician regarding Resident #18 missing the diuretic medication. She stated Resident #18 did not voice any concerns or complaints to her and it was her understanding that the medication would be delivered that Saturday, and that was why she didn't inform the physician about Resident #18 missing doses of the medication. She stated she did not call the pharmacy again on that Sunday because it was to her understanding that the pharmacy did not deliver medications on Sundays. She stated she was in-serviced on reordering medications and medication errors on 08/10/23. She stated the in-services covered missed doses of medication and explained what to do in the future and how to handle it if a resident missed a dose of medications. She stated she would call the emergency pharmacy number and see if the medication could be delivered and if medication was still unavailable, she would contact the physician and see what the physician wanted her to do and follow those orders anytime a resident was out of their medication. During an interview on 08/15/23 at 5:53 PM with the ADM, she stated medications should be administered to residents as ordered by physician. She stated she did not administer medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given or missed doses of medication, staff should contact the charge nurse and DON, contact the pharmacy to order the medication, and contact the medical director to inform of the situation. She stated if a medication is missed there is a risk for potential harm. She stated if the medication missed was a diuretic medication, it could cause possible heart issues if a resident had a diagnosis of congestive heart failure. She stated regarding the incident involving Resident #18 , where resident missed 12 doses of ordered diuretic medication, the missed medication was discovered, and she was informed. She stated she alerted her chief officer of operations of the facility, Resident #18's responsible party, and HHSC. She stated the Medical Director was notified upon discovery of missed medications. She stated the nurse should have notified the doctor with the first dose of medication. She stated she in-serviced staff on reordering medications and medication errors. She stated the in-services covered missing medications and what to do in the case of a resident missing a medication. She stated staff should now be notifying the medical director and following orders, notifying the pharmacy and using the emergency protocol to get the medication here to the facility STAT anytime a resident is out of their medication. Record review of facility's undated policy titled Administering Medications - Oral revealed: To ensure that medications are administered within the restrictions of employee licensure and per regulation and best practice in the industry. Procedure: Administering Oral Medications: General guidelines and precautions: 5. Follow the six rights of medication administration. - Right patient, right drug, right dose, right route, right time, right documentation. 7. If a medication is unavailable or missing, notify the charge nurse. a. unavailable medication: charge nurse will check the E-kit to see if the dose is available. If not in the E-kit, the charge nurse will reach out to the facility pharmacy to initiate emergency refill if the cutoff time has already passed for the next scheduled delivery. Record review of facility's undated policy titled Receiving medications from the pharmacy revealed: It is the policy of this facility to assure all medications are correctly delivered and errors rectified as soon as possible, to assure proper handling of all medications and to assure a system is adhered to at all times. On 08/15/23 at 3:22 PM, an Immediate Jeopardy (IJ) was identified. The ADM and DON was notified on 08/15/23 at 6:57 PM. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. Record review of facility plan of removal for pharmacy services revealed: Facility Policy on Administering Medication - Oral - In-services on the following topic Administering Medication Policy began on 8/16/23 and were completed with current RN, LVN, and Medication Aides on 8/16/23. The Administering Medication policy was revised by the Chief Operations Officer on 8/15/2023 to instruct the RN, LVN, and Medication Aides what actions to take if a medication is unavailable or missing. If medication is unavailable or missing the charge nurse will be notified by the Medication Aide. If unavailable the charge nurse will check the eKit, and if not in the eKit the charge nurse will contact the pharmacy for emergency refill immediately. If medication is missing the charge nurse will search for the medication. If the medication is not located, the charge nurse will notify the Director of Nursing and facility administration immediately to initiate an investigation. RN, LVN and Medication Aides currently on shift will pass a post-test of 5 questions to demonstrate competency/understanding of what to do when medication is unavailable or missing and a required grade of 100%. If they fail, they will be immediately reeducated by the DON and/or nurse educators and required to retake the post-test and achieve 100%. RN, LVN and Medication Aides not currently on shift will be in-serviced before taking any assignment in the facility by 8/17/2023. The DON was in-service by the Director of Clinical service on 8/16/20203. The nurse educators will be in-service by the Director of Nursing on the Administering Medication-Oral Policy and Physician Notification by 8/16/2023 and then the DON/RN, and both ADON's will educate the RN, LVN and Medication Aides from 8/16/2023-8/172023. All new hires that are Med Aides or Nurses will receive training on the same topics during new employee orientation. The DON, ADON, and Administrator performed an audit from the 24-hour report on 8/08/2023 to ensure no other residents had missing or unavailable medication, and there were no other discrepancies. All remaining Nurses and Medication Aides not present will be required to be in-serviced on the above topics and pass the post-test for prior taking any assignment in the facility. The Director of Nursing and Administrator will monitor the 24-hour report to ensure all medications have arrived from the pharmacy and administered to residents as prescribed. The medical provider, and medical director will be notified by the charge nurse immediately of any medication pending delivery from pharmacy and request for alternative order if unable to be filled. The nursing staff was in service on notifying the medical director from 8/16/2023-8/17/2023. A Quality Assurance Performance Improvement meeting was held on 8/16/2023 to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified on 8/15/23 of the Immediate Jeopardy The Director of Nursing and the Administrator will review the 24-hour report Monday-Friday and the weekend report will be reviewed on Monday, promulgated by electronic records system to review any medications listed as not given, NA, or medication on order and will follow-up immediately with the pharmacy and/or physician or other mid-level practitioner assigned to the residents care to ensure appropriate follow through. The following was monitoring of the facility's corrective actions between 08/16/23 and 08/18/23: During an interview on 08/16/23 at 9:03 AM with the MD, she stated if she was made aware that Resident #18 was missing doses of medication, she would have substituted the medication for something else or arranged for the medication to be picked up by family or staff at a local pharmacy. She stated she was not made aware of the medication not being administered until 08/07/23. During an interview on 08/16/2023 at 1:32 PM with MA E, she stated she was in-serviced on 08/16/23 regarding policy for passing medications correctly and it incorporated who to notify in different instances. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would notify her charge nurse. She stated it was true that if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would notify the Administrator. She stated anytime a resident missed a dose of medication, she would notify her charge nurse. During an interview on 08/16/2023 at 1:58 PM with LVN F, she stated she was in-serviced 08/16/23 regarding medication administration and what to do if they do not have a medication available. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would call the pharmacy and call the provider to get any new orders, or for a local pharmacy to send out within 24 hours so that she could give the medication. She stated it was true that if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would notify the residents provider to see if provider wanted to put it on hold or whatever next steps to follow and contact the pharmacy to get the medication in the facility. She stated anytime a resident missed a dose of medication, she would notify the provider. During an interview on 08/16/2023 at 2:38 PM with MA G, she stated she was in-serviced 08/16/23 regarding policies about administering medications and notification to physician and family. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would notify her charge nurse. She stated if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would notify her charge nurse. She stated anytime a resident missed a dose of medication, she would notify the charge nurse. During an interview on 08/16/2023 at 2:59 PM with LVN H, she stated she was in-serviced 08/16/23 regarding medication administration and what to do if medications were not in the facility. She stated they went over when to notify physicians and responsible parties as well. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would look for the medication, call the pharmacy to try to get the medication here in the facility, if they could not get it when needed, she would call the doctor to get a hold order for the medication. She stated it was true that if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would call the doctor and pharmacy. She stated anyti[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident # 1) reviewed for accident hazards and supervision. The facility failed to ensure CNA A used a gait belt while ambulating Resident #1 to the dining hall on 04/30/2023, Resident #1 fell and sustained a fracture of the right distal radial. An Immediate Jeopardy (IJ) situation was identified on 05/16/2023 at 3:19 p.m. While the IJ was removed on 05/18/2023 at 8:57 a.m., the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for accidents, falls, fractures, and a diminished quality of life. Findings include: Record review of Resident #1's, undated, face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included repeated falls, Parkinson disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), displaced fracture of right ulna styloid process (the styloid process of the ulna is a bony prominence found at distal end of the ulna in the forearm.), subsequent encounter for closed fracture with routine healing; other intraarticular fracture of lower end of right radius, subsequent encounter for closed fracture with routine healing dated 04/30/2023. Record review or Resident #1's fall risk assessment, dated 1/19/2023, reflected a score 12, with 10 or greater being high risk for fall. Review of document presented by the therapy department titled Walking: to dine/around the facility/wherever you would like to walk Resident indicated Resident #1 was placed on the list as of 02/17/2023. Record review of Resident #1's POC for CNAs, dated 02/20/2023, reflected: Walk-to-dining program: assist resident to walk to and from dining room for all meals with RW SBA and gait belt donned. Record review of Resident #1's quarterly MDS assessment, dated 03/11/2023, revealed a BIMS score of 11, which indicated moderate impaired cognition. It was also revealed Resident #1 required 1-person physical assist with walking in the corridor. Record review of Resident #1's Care Plan, dated 03/25/2023, revealed Resident #1 was at risk for falls due to Parkinson's, Syncope/collapse, unsteady gait, decreased balance, medications, and poor safety awareness. Resident #1 used a mobility device, required assistance with transfers- observe resident when ambulating for unsteady gait, dizziness, decreased balance, weakness and provide assist as needed, provide assistance to keep area of ambulation free from cluster, trip, spill hazards. Record review of Resident #1's incident report, dated 04/30/2023, reflected Resident #1 had a fall while going to the dining hall for lunch. It was also indicated the corner of Resident #1's walker got stuck by the wall and the resident complained her arm hurt after the fall. Record review of Resident #1's progress notes, dated 04/30/2023, at 12:42 p.m., written by LVN A, reflected the following: Resident was taken to the emergency department after sustaining injuries from a fall. Incident took place around 11:30 AM and picked up by ambulance around 11:52 (a.m). Doctor, DON, and family notified. Incident report completed. Record review or Resident #1's fall risk assessment, dated 04/30/2023, reflected a score 14, with 10 or greater being high risk for fall. Record review of Resident #1's local hospital record, dated 04/30/2023, reflected an X-ray result, with 2 views of the right wrist: Findings: Interval reduction of acute, obliquely oriented fracture of the distal radial metaphyseal region with improved alignment. Displaced ulnar styloid avulsion (caused by traction from ligamentous structures, often from a fall onto an outstretched hand, and typically results in a stable styloid tip fracture) fracture is again noted. Scattered osteoarthritis of the right wrist. (Radial fracture is a break in the radius bone. The radius is a bone in the forearm, on the same side as the thumb. The forearm is the part of the arm that is between the elbow and the wrist. A radial fracture near the wrist (distal radio/fracture) is the most common type of broken arm.) In an interview on 05/16/2023 at 12:09 p.m., CNA A stated she was the staff who assisted Resident #1 with ambulation to the dining hall on 04/30/2023 when she fell. CNA A stated she and Resident #1 were walking, she (CNA A) was halfway side and halfway back of Resident #1 while they were walking. CNA A stated she and Resident #1 were rounding the corner to the dining hall when Resident #1' s walker remained standing while Resident #1 fell. CNA A stated she grabbed Resident #1 by the back of her pants for balance, but she still fell. CNA A stated she was supposed to apply a gait belt on Resident #1, but she (CNA A) was in a hurry, so she did not apply the gait belt. CNA A stated she was trained on how to transfer a resident with a gait belt from the bed to the chair and vice versa but not on ambulation. In an interview on 05/16/2023 at 11:42 p.m., the DOR stated Resident #1 was on a walk to dine program prior to her fall on 04/30/2023. The DOR stated the CNAs were supposed to have a walker, a wheelchair and a gait belt when assisting a resident to ambulate to the dining hall. She stated the therapy department communicated with the nursing department before Resident #1 was transferred to the CNAs for the walk to dine program that Resident #1 required standby assist with a gait belt for ambulation. In an interview on 05/16/2023 at 12:42 p.m., the DON stated she was aware of Resident #1's fall on 04/30/2023. The DON stated Resident #1 was ambulating to the dining hall while assisted by CNA A, Resident #1's walker hit the wall and she fell. The DON stated the therapy department usually communicate with nursing department when a resident is being put on the walk to dine program by indicating how much assistance was needed. She stated the communication from the therapy department was put in the POC for the CNAs to know how much assistance Resident #1 needed for mobility/ambulation. The DON stated, while she looked at the POC for Resident #1's mobility, the POC was printed directly from the CNAs POC for Resident #1 and CNA A should have known to apply a gait belt while she assisted Resident #1. The DON stated a gait belt should be in place when transferring and ambulating a resident. In an interview on 05/17/2023 at 10:05 a.m., the PTA D stated she worked with Resident #1 prior to her fall on 04/30/2023. She stated she communicated with nursing about Resident #1's walk to dine program and how much assistance was needed. PTA D stated she specifically spoke with CNA A on how to ambulate Resident #1 to the dining hall. The PTA D stated when a Resident #1 was stand-by assist, the staff still had to don a gait belt for safety. The PTA D stated, depending on what the resident was wearing, you could not hold the balance by grabbing their clothes, so it was advisable to use a gait belt. She also stated, if someone fell and there was no gait belt to hold, that's liability issue. In an interview on 05/16/2023 at 11:25 p.m., the Medical Director stated the nursing staff were supposed to get approval from the family and medical team for therapy recommendations. She stated the CNAs were expected to follow the POC entered into PCC for any given resident. She stated if the POC for Resident #1 indicated CNAs had to don a gait belt when ambulating, the CNAs were expected to don gait belt. In an interview on 05/17/2023 at 3:23 p.m., LVN C stated he was the nurse in charge of Resident #1 on 04/30/2023 when she fell. He stated he heard a commotion from the hall close to the entrance of the dining hall like someone had fallen. He stated CNA A stated the fall happened so fast and she was not able to catch Resident #1. He stated CNA A would have used the gait belt to catch Resident #1. He also stated, after the fall, he did not look to ensure the gait belt was on Resident #1 while she was on the floor. LVN C stated Resident #1 required a gait belt, walker and wheelchair while being ambulated. He stated Resident #1 had history of falls and fracture and required cautions during ambulation. Interview on 05/17/2023 at 3:40 p.m., the DON stated she did not know CNA A did not use a gait belt while ambulating Resident #1 on 04/30/2023 until the State Surveyor began asking questions. She also stated she is not sure if Resident #1's fall would have been prevented if a gait belt was applied. Record review of the facility's, undated, policy titled General Safety Policy reflected the following: In general, all employees will maintain a safe environment and report any issues immediately . Employees should be cautious when walking or pushing carts around [NAME] corner Record review of the facility's, undated, policy titled Fall and Post-Fall Management reflected the following: Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for resident as well as staff safety. Discussions regarding the acceptable level of risk must be based on individual assessment with input from the resident and/or Substitute Decision Maker (SDM) and interdisciplinary team with these notes documented in the resident medical chart and care plan. .Identify residents at risk for falls during ADL execution by resident individually or with staff assistance .Initiate preventative approaches where appropriate. Provide appropriate strategies and interventions directed to resident, environmental factors and staff. Record review of the facility's, undated, policy titled Ambulation with or without gait belt reflected the following: Licensed Nurse and Nursing Assistant, Restorative Nursing Assistant, Physical Therapist and Occupational Therapist . ? To assist resident to achieve maximum function. ? To provide assistance to resident that is identified as requiring such assistance. ? To supervise and assess resident function in order to plan care to maintain optimum ambulation function as long as possible. ? To re-educate resident in ambulation techniques. ? To teach resident use of assistive devices (where necessary) tco maintain optimum ambulation function as long as possible. ? To reduce risk of falls and injury. Procedure: The following is suggested for those residents that require assistance with ambulation . Review the [NAME] in Point Click Care for the MOBILITY STATUS (example: their level of required assistance such as . use of gait belt per their required level of assistant to include Stand-by-Assist and Contact Guard assist or greater.) 3. Move behind and slightly to one side of the resident. 4. Encourage resident to stand until good balance 1st established. 5. During ambulation, position yourself on the resident's strong side. 6. Walk with the resident with your gait matching the resident's gait. This was determined to be an Immediate Jeopardy (IJ) on 05/16/2023 at 3:19 p.m. The Chief Operational Officer, DON and the Administrator in Training were notified. The Chief Operational Officer, DON and the Administrator were provided with the IJ template on 05/16/2023 at 3:19 p.m. The following Plan of Removal submitted by the facility was accepted on 05/18//2023 at 8:57 a.m.: Plan of Removal - 5.16.23 SUBMISSION #5 Events Leading to the Deficient Practice: Due to the resident not wearing the gait belt as recommended by therapy, during a survey visit for a self-report and complaint, and Immediate Jeopardy was called on 5/16/2023 and the official l IJ Template was received by this facility at 3:19pm on the same day. Other residents affected Three (3) current residents on the Walk-to-Dine designation as recommended by the therapy department have the potential to be affected by the deficient practice. The failure is as follows: The CNA walking with the resident did not don the gait belt on the resident per therapy recommendation. fll-ser vici 11g/education provided in response: I. Facility Policy on Ambulation - In- services began on 5/16/23 and were completed with current nursing staff on 5/17/23. All employees currently on shift will pass a post-test of 5 questions pertaining to the policy to demonstrate competency/understanding and a required grade of 100 %. If they fail, they will be immediately reeducated and required to retake the post-test and achieve 100%. All other nursing staff not currently on shift will be in-serviced before taking any assignment in the facility. The nurse educators will be in-serviced by the Director of Rehab on the Ambulation Policy and then the DON/RN, and both ADON' s will educate the nursing staff on the Ambulation Policy. All new-hire s will receive training g on the same topics during new employee orientation and prior to providing resident care. 2. Facility Policy on Gait Belt usage - In-services began on 5/16/23 and were completed with current nursing staff on 5/17/23. All nursing employees currently on shift will pass a post-test 5 questions pertaining to the policy to demonstrate competency/understanding. If they fail, they will be immediately reeducated and required to retake the post-test and achieve I 00 %. All other nursing staff not currently on shift will be in-serviced and a post-test administered before taking any assignment in the facility. The nurse educators will be in-serviced by the Director of Rehab on the Gait Belt Policy and then the DON/RN, and both ADON's will educate the nursing staff on the Gait Belt Policy. All new- hires wi ll receive training on the same topics during new employee orientation and prior to providing resident care. 3. Facility process on how to access the [NAME] in Point Click Care - In-services began on 5/16/23 and were completed with current nursing staff on 5/17/23. All other nursing staff not currently on shift will be in-serviced and a post-test administered before taking any assignment in the facility. The DON/RN, and both ADON' s will educate the nursing staff on accessing the [NAME]. All new hires will receive training on the same topics during new employee orientation and prior to providing resident care. NOTE: all remaining nursing staff not present will be required to be in-serviced on the above topics and pass the post-test for #1/#2 combined, and #3 prior taking any assignment in the facility. Staff Reprimands 1. CNA will be terminated from employment on 5/17/2023 prior to clocking in for her regular shift A Quality Assurance Performance Improvement meeting was held on 5/16/2023 to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. All Walk-to-Dine recommendations for Residents #2, #3, and #4 were notated and communicated by the Director of Therapy to the Director of Nursing and care plans were updated by the MDS nurse to reflect the therapy recommendations for the Walk-to-Dine designation and was confirmed to be in place by the Director of Nursing. Monitoring For the next 30 days, the Director of Nursing will monitor three (3) nursing staff per week on the above listed educational topics and the post-test given (those with such a created post-test) to determine retention of knowledge. Should a staff member fail the post-test immediate reeducation will be provided, and the post-test administered again until 100%. For the next 30 days, the Director of Nursing will monitor the three (3) residents with a Walk-to-Dine designation to ensure that they are being appropriately ambulated with as recommended by therapy and that a gait belt is present. Preventing Reoccurrence The facility will utilize the Point Click Care [NAME] section to communicate with nursing staff related to the MOBILITY STATUS of the residents. Therapy recommendations specific to MOBILITY STATUS surrounding Walk-to Dine designations will be reviewed weekly in the Standards of Care Meeting and the [NAME] updated accordingly when someone is added or removed from such a program. Monitoring of the plan of removal was completed on 05/18/2023 through 01/13/2023 and revealed the following: During an observation on 05/18/2023 at 11:36 a.m., Resident #2 was observed being ambulated to the dining hall for lunch by CNA B. Resident #2 was noted with his walker and gait belt around his waist while CNA B was observed holding the gait belt attached to Resident #2's waist, a wheelchair, walking behind Resident #2. During an interview on 05/18/2023 at 11:05 a.m., the Chief Operational Officer stated he filled in for the Administrator position. He stated the staff were expected to present therapy recommendations to the IDT for discussion and approval. He stated the CNAs were expected to follow Resident's task in the [NAME] that were communicated to them. He stated Resident #1 was stand by assist and not contact guard, meaning the staff did not have to touch Resident #1, and was not sure if the gait belt would have prevented the fall from occurring. He stated QAPI had a meeting on 05/16/2023 after the IJ was called to discuss the POR. He stated the facility-initiated trainings for staff on 05/17/2023, Ambulation with or without gait belt. Accessing the [NAME] from PCC to verify walk to dine, and they were being trained before working the floor. In an interview on 05/18/2023 at 11:30 a.m., CNA G stated he was trained on 05/16/2023 on how to pull resident's information for care in PCC on the kiosk. He stated each hall had a kiosk, CNAs were trained to log onto PPC, find the resident, go to [NAME], and look for mobility or any other care are. He also stated he was trained on the proper use of gait belt. He stated there were 3 residents in the facility that were on the walk to dine program, he listed the 3 residents and stated gait belt was required for ambulation with those residents. In an interview on 05/18/2023 at 11:40 a.m. CNA B stated she was trained/in-serviced on 05/17/2023 and 05/18/2023 on how to use the kiosk to log into PCC, select a resident, select [NAME] and check the mobility status. She stated after the training, she took a test, made 100 percent in the result. She stated she was also trained on how to walk Residents to the dining hall. She stated there were 2 residents on her assigned hall that were on the walk to dine program. In an interview on 05/18/2023 at 11:56 a.m. CNA H stated she was trained on 05/17/2023 and 05/18/2023 on how to use the kiosk to log into PCC, select a resident, select [NAME] and check the mobility status. She stated she took a test after the training and had to get a 100 percent result. She stated she was trained on how to ambulate a resident to the dining hall who was on the walk to dine program. She stated she had 1 resident who was on the walk to dine program on her assigned hall Interview with the DON, ADON E, the MDS nurse, 2 LVNs and 3 CNAs all reflected they were trained and in serviced on ambulating a resident with or without gait belt, how to access the [NAME] through PCC to verify walk-to-dine at the beginning of their shifts. They all were able to state the process of verifying resident's mobility needs and how ambulate a resident. They were all aware of Residents that were on the walk to dine program in the facility. In an interview on 05/18/2023 at 12:46 p.m., the DON stated she and the 2 ADONs were trained by the DOR, and they were responsible to train other staff. She stated the ADONs were focused on training the staff while she was focused on monitoring staff to ensure the trainings were effective. The DON also stated there were 3 residents in the facility who were on the walk to dine program. Record review of the facility's POR documentations reflected the QAPI team met on 05/16/2023 and the MD attended via phone. Record review of facility's Inservice, dated 05/17/2023, reflected the following trainings were instructed by the DOR and participants were the DON, ADON E and ADON F, post test results were attached: Ambulation with or without gait belt. Accessing the [NAME] from PCC to verify walk to dine. Record review of facility's Inservice, dated 05/17/2023, reflected the following conducted by ADON E, ADON F and participants were other CNAs and nurses: It was also reflected that there was a checklist to indicate staff that had been trained along with post test results with passing mark of 100 percent. Ambulation with or without gait belt. Accessing the [NAME] from PCC to verify walk to dine. The DON and the Administrator in Training were informed the Immediate Jeopardy was removed on 05/18/2023 at 1:14 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.