**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications) for 1 (Resident #21) of 3 residents reviewed for change in condition. The facility failed to immediately notify Resident #21's physician before 11/29/23 at 8:30am when Resident #21's radiology report dated 11/28/23 at 5:51pm reflected that Resident #21 had a displaced fracture of her left femur neck (top of the thigh bone at the hip) that occurred when Resident #21 fell in the facility's dining room three days before the x-ray was completed on 11/28/23. On 9/18/24 at 2:06pm an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on 9/20/24 at 1:35pm, the facility remained out of compliance at a scope of isolated with a severity of no actual harm with potential for more than minimal harm that was not Immediate Jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of a delay in treatment, decline in physical, mental, and/or psychosocial status, hospitalization, and even death. The findings included: Record review of Resident #21's face sheet reflected an [AGE] year-old female that was admitted to the facility on [DATE] with a primary diagnosis of encounter for palliative care (care focused on improving quality of life for people with serious illnesses). Other pertinent diagnoses included congestive heart failure (the heart didn't pump blood effectively and could cause fluid buildup in the lungs), dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), inflammatory polyneuropathy (an auto immune attack on the peripheral nerves that can cause progressive muscle weakness, numbness, loss of reflexes, and pain or tingling in the arms, hands, legs, and feet), major depressive disorder, chronic kidney disease-stage 3 (mild to moderate kidney damage), dyspnea (shortness of breath), edema (swelling), muscle weakness, and muscle atrophy (wasting or loss of muscle tissue). There were no diagnoses related to liver damage or liver failure. Record review of Resident #21's admission MDS dated [DATE] reflected she had a BIMS score of 00 which indicated she had severe cognitive impairment. Record review of Resident #21's care plan dated 10/27/23 with revisions on 10/30/23, 11/29/23 and 12/6/23 reflected in part: Focus: I have impaired cognitive function/dementia or impaired thought process r/t (Specify). Goal: I will (Maintain or improve) current level of cognitive function through the review date. Interventions/Tasks: Communicate with me, my family/caregivers regarding my capabilities and needs, Notify MD of any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Focus: I have a communication problem: Goal: I will be able to make basic needs known by (verbally/however able to express) on a daily basis through the review date. Interventions/Tasks: Anticipate and meet my needs. Notify MD PRN for changes in ability to communicate, potential contributing factors for communication problems, potential for improvement. Focus: I am at risk for falls r/t [left blank] Goal: I will be free from falls and/or will not experience significant injuries associated with falls through the next review date. Interventions/Tasks: Refer to therapy for screen and/or eval as indicated. Focus: Advanced care planning choices for end-of-life care: Hospice care elected. Goal: I will have my comfort, quality of life and dignity protected an honored through my next review date. In a phone interview on 9/12/24 at 10:05am Resident #21's family member stated that Resident #21 had a history of breast cancer and colon cancer but had received PET (Positron emission tomography) scans for at least the last 3 to 5 years prior to her admission to the facility that showed no cancer anywhere. Resident #21's family member stated that Resident #21 did not have any history of liver damage or liver failure and that Resident #21's primary care physician prior to going on hospice had told Resident #21 and her family member that her kidney disease was stable. Resident #21's family member stated that the reason Resident #21 went into the facility with hospice care was because Resident #21's dementia had progressed to the point that the family member could not take care of her at home anymore. Resident #21's family member stated that Resident #21 went back to the family member's house on 11/30/23 with hospice services because the emergency room physician and the surgeon told the family member that surgery for Resident #21's left hip fracture was not an option due to the resident now having kidney and liver failure. Resident #21 passed away at home on [DATE]. Record review of Resident #21's progress notes section in the facility's PCC system reflected an entry dated 11/25/23 at 2:38pm by RN I that stated, Resident stood up on her own out of her wheelchair in dining room, did not take any steps but lost her balance and CNA was standing near resident and resident went to the floor, landed on her left side, CNA who witnessed the fall cradled residents head and resident did not hit her head or face on the floor Resident checked for injuries, denies pain, and assisted by 3 staff members back into her wheelchair, DON, RP, and Medical provider notified. Resident taken to her room and vital signs taken and head to toe assessment completed. [sic] Record review of the facility's PCC assessments page for Resident #21 reflected an eINTERACT Change in Condition Evaluation that was entered on 11/25/23 in reference to Resident #21's fall in the facility's dining room on the same date that stated in part, Resident #21 had no complaints of pain. Resident [#21] had a witnessed fall with neuro checks intact, moves all extremities, and no s/s of injuries, skin checked for discoloration none noted at this time [sic]. This document reflected that the physician was notified of Resident #21's fall on 11/25/23 at 2:45pm and the physician's recommendation was to refer Resident #21 for a physical therapy evaluation In an interview on 9/11/24 at 3:50pm, the DON stated, We did not do x-rays at the time [of the fall] because when I looked at the camera, she was self-propelling in the dining room. She was shaking a doorknob and kind of slid out of her chair onto the floor. She did not actually stand and fall. She did not have any bruising at that time. She was being medicated for pain on the 25th (November 2023) because she was post fall and couldn't tell us I have pain here. She just had signs and symptoms of pain. We got an x-ray on the 28th. I don't remember why or what her signs and symptoms were. With hospice patients, hospice won't order x-rays, so we contacted our doctor instead of the hospice physician and that's why there was a delay from the complaint of pain on the 27th to the order on the 28th (of November 2023) In an interview on 9/13/24 at 12:48pm, CNA M stated, On 11/25/23, Resident #21 was in the dining room toward the kitchen washroom area. I was passing by taking people out of the dining room. I saw her getting up off the wheelchair and standing. Once I saw her taking some steps and was unbalanced, I knew she was going to fall so I sprinted over there to try to catch her. It was kind of a slow fall. She was not quite on the floor when I got to her, so I made sure she did not hit her head. When she was on the floor, she was kind of on her left side. Two other people saw it as well and came in to assist me to get her back to her chair. She said she was in pain after that. I can't remember if she said her arm or her hip, but she was saying, ow- it hurts, it hurts. She was just kind of whimpering and saying she hurt when she was assisted back into the wheelchair. Record review of Resident #21's MAR dated November 2023 reflected that Resident #21 had an order for Tramadol HCl (a pain medication) oral tablet 50mg to be given by mouth every six hours as needed for pain. Resident #21 did not have any other medications ordered for pain relief. Resident #21 was given Tramadol 50mg on 11/25/23 at 6:25pm for generalized pain at level 5 out of 10 (10 being the worst pain), 11/26/23 at 3:53pm for generalized pain at level 2 out of 10, and 11/26/23 at 10:00pm for generalized pain at level 5 out of 10. On 11/27/23 at 5:44am, LVN J gave Resident #21 Tramadol 50mg for left shoulder and left leg pain at level 10 out of 10. Record review of Resident #21's progress notes page dated 11/6/23 to 12/6/23, assessments page dated 10/27/23 to 11/29/23 in the facility's PCC system and a telephone interview of LVN J on 9/16/24 at 11:48am reflected that Resident #21's physician was not notified of her significant increase in pain on 11/27/23 by LVN J at the time she medicated Resident #21, nor any other time that day. LVN J stated she did not recall why she did not notify the doctor when Resident #21 complained of a 10 out of 10 pain level. LVN J stated if someone fell, she would do range of motion and check them out; if the resident had complained of pain during that, LVN J stated she would have notified the doctor and gotten an x-ray. LVN J stated when an x-ray was done, the nurse would have had to look for the results and that there was no flag or anything to let the nurse know that the results were posted. LVN J stated if she was going off shift, she would pass it on to the next shift to look for the results. LVN J stated they would not be notified by the radiology company. LVN J stated sometimes the x-ray technician would let them know if something did not look right and to keep an eye out for the report. LVN J stated if she pulled up an x-ray report and something looked abnormal or bad, she would notify the physician right away- as soon as she saw the result. LVN J stated she did not know if anyone at the facility got notified automatically of results. LVN J stated that she worked at the facility until March 2024 and had been there for about a year. LVN J stated they discussed notification of changes almost every day and had once a month in-services on various topics. Record review of Resident #21's Physician Orders reflected a left shoulder and hip/pelvis x-ray ordered by RN K on 11/28/23 at 11:30am. Record review of Resident #21's printable view progress notes dated 11/29/23 at 8:34am reflected an entry by RN I that stated, Xray report from Xray of 11/28/23 reviewed and reported to medical provider left shoulder x ray showed no acute fracture, RP states she will think about the situation, but shows grossly displaced femoral neck fracture of left hip, acute fracture. Medical provider recommends send resident too [sic] ER (Emergency Room) for evaluation of left hip fracture. DON notified. And RP notified and will think about whether she wants notify Nurse when she makes a decision on sending the resident sent out to ER, states she will call back to notify this facility. Call out to the hospice company to notify of positive left hip fracture, left msg to have hospice return my call. [sic] Record review of the facility's PCC assessments page for Resident #21 reflected an unsigned eINTERACT Change in Condition Evaluation that was dated 11/29/23 and revealed the situation being reported was Trauma (fall related or other) and that Resident #21 had new pain, left hip pain/left iliac crest (rear)/Left trochanter (hip) and intensity of pain 2 of 10. In the area for observation and evaluation summary, the author documented, Results of x ray to hip positive for Grossly displaced femoral neck fracture of left hip with no discoloration to area. Resident does have pain on left hip, with pain medication. Medical provider notified and recommends to send resident out to ER for evaluation, DON notified of Results of left hip X RAY and RP notified states since resident is hospice, she will need to decide whether she wishes to send resident out to ER, will notify nurses of her decision [sic]. This document also stated that Resident #21's physician was notified on 11/29/23 at 8:40am and the physician recommended Resident #21 be taken by non-emergent transfer ambulance for evaluation of left hip fracture to the ER. In a telephone interview on 9/13/24 at 10:21am a supervisor for the facility's contracted radiology company stated that the result of the left shoulder and hip/pelvis x-ray was automatically delivered by email to the facility's DON and administrator on 11/28/23 at 5:51pm. The supervisor stated that the result was also automatically faxed to the facility's fax number on record on 11/28/23 at 5:51pm, but that it failed. The supervisor stated there was no documentation that the radiology company called the facility to report the significant findings of the x-ray. In an interview on 9/11/23 at 3:56pm the DON stated, If there is a significant finding for an x-ray, I receive an email and they call the facility within, I think, 24 hours. I received the email at 5:51pm (on 11/28/23). Even if I was gone for the day, I would check my email from home. I may have been out with the flu or COVID at that time, but I remember calling the facility that evening. I can't say why the physician was not notified until 8:30 the next morning or why the nurse didn't document anything. The physician and RP should have been notified that evening. A lot of the longer tenure nurses will want to notify the hospice doctor before the facility doctor because they are hospice, but we don't have documentation of that either. If the physician and RP are not notified, it could lead to negative outcomes including untreated pain or worsening of a fracture. The physician and RP should be notified immediately when critical results are received. The DON did not state who she talked to when she called the facility on 11/28/23 about the x-ray results. In a telephone interview on 9/13/24 at 11:00am the MD stated he would expect the doctor or nurse practioner to be notified of any critical/significant results with 30-45 minutes. The MD stated he did not know if it would have made a difference if he had been notified of Resident #21's fractured femur the evening before. The MD stated, if for some reason the facility was unable to contact either the NP or himself, they should just go ahead and send the resident out to the ER. The MD stated that when Resident #21 was treated for 10 of 10 pain specifically to her left leg and shoulder on 11/27/23 following a fall on her left side on 11/25/23, he or the NP should have been notified. The MD stated, What we know of hip fractures in older adults, we need to intervene sooner rather than later because being in bed for three days, especially if they are in pain and probably not eating or drinking well, it can lead to multi organ failure. If we had known about the fracture and intervened earlier, she may have lived a little longer. The MD stated that it was ultimately a hospice decision to x-ray a hospice patient, but if she had not been a hospice patient, it would have been prudent to do an x-ray at the time of the fall. In an interview on 9/13/24 at 1:11pm the ADON stated for critical findings, the lab or radiology would call the facility and would ask for the nurse of that specific resident. The nurse would talk to them and get the results. After the nurse received the critical or significant finding information, he/she would then call the doctor and see if there were any new orders. The ADON stated, We call the doctor immediately when we have critical results. The ADON stated, That I know of there isn't a specific policy in writing about when to notify the doctor of critical results. In an interview on 9/16/24 at 10:15am, CNA B stated that Resident #21 was on pain meds and would complain of pain mostly in the mornings and later in the day. CNA B stated when Resident #21 was first admitted she was good until the fall on 11/10/23 . After that fall, she got more confused and complained of more pain. I know she was always getting in and out of her chair. CNA B stated if a resident had a bad fall or had to be assessed by physical therapy, the CNAs would not get the resident out of bed until physical therapy saw and assessed them. CNA B stated, I don't recall her (Resident #21) falling at all when I worked on 11/27/23 or 11/28/23 and it was not reported to me that she fell any time after 11/25/23. After the fall, family was here more often than before. I don't think she was eating very well that week. There's nothing more that I can recall. In an interview on 9/16/24 at 11:12am, RN K stated she kind of remembered Resident #21 but did not remember anything specific about the week after Resident #21 fell on [DATE]. RN K stated if she had a resident that had fallen two days prior and then started complaining of a significant increase in pain, she would notify the NP or the doctor to advise them of the increase in pain on the side the resident had fallen on two days before. RN K stated if it was a hospice patient, she would notify the facility (primary) doctor or NP, then hospice. RN K stated in most cases, she would call the facility attending and then let hospice know that she notified the primary doctor. RN K stated if there was an abnormal finding on an x-ray, the radiology company posted the results on the website. RN K stated she did not think the facility got called if there were significant findings. RN K stated she thought that once the results got posted, the facility doctor looked at the results and it went from there. RN K stated she did not recall any time when the DON or ADON went to her and said that there was an abnormal x-ray result and for her to notify the physician. RN K stated if the nurse found something (a significant finding) before the doctor did, then the nurse would call the doctor immediately. RN K stated if the nurse was not able to contact the doctor, he/she was to contact the DON to let her know so that she could follow up. RN K stated the x-ray technician would not tell the nurse if they saw something abnormal on the x-ray. RN K stated that sometimes x-rays would result right away, but sometimes they took a very long time. In an interview on 9/16/24 at 12:24pm, the DON stated, At that time when abnormal or critical x-rays were received, the facility would receive a phone call with the results. I would also get an email for significant findings. Normally, if I wasn't at the facility, I would call to make sure the nurse knew of the findings. Let's say I didn't see the email or get the email; the x-ray people would call the facility and we could get into the portal and print out the x-ray results. X-ray will call, but sometimes they don't call until the next day. If it was the next day, it was like a follow up call when they'd ask if we saw it. If the facility is notified of an abnormal result (for hospice) it would depend on the nurse whether the primary physician or hospice would get notified first, but they would both be notified. The nurse would need to notify the doctor as soon as they found out about it. In reference to (Resident #21's) x-ray result, I got the email on 11/28/23 at 5:51pm. I was not here (at the facility) at the time, and I don't remember if I called the facility or not. The DON stated that the floor nurse would have had to go into the portal to see if the x-ray result was there. The PCC system did not flag or alert when an x-ray was resulted, the nurse would have to check. The DON stated if the x-ray was not resulted during the day shift, the day shift nurse would pass on to the night shift nurse to look out for the result. If for some reason the night shift nurse did not get the result, then the day shift nurse would follow up the next morning. The DON stated, In general, if there was a critical or significant finding, the physician should have been notified right away. Notification 15 hours later is generally not acceptable. There may be times when that would be ok, but in this particular case, no. The DON stated, She (Resident #21) wasn't x-rayed the day of the fall because she didn't display any signs or symptoms of pain; not even when they were getting her off the floor initially. If she had a significant increase in pain 2 days post fall, it would warrant a notification to the doctor. The DON stated it was important to notify the physician of any significant change in condition or results of diagnostics so that they could provide the best quality of care for the resident. The DON stated if the physician was not notified of changes, the resident's quality of care could have been affected, the resident may not have gotten needed treatment, services, or medication, the resident could have been hospitalized , or it could have even led to death. The DON stated, The policy does not have a specific time frame for notification. The DON stated when a physician was notified of results or a change of condition, documentation included dated and time of notification of provider and RP and any new orders. In an interview on 9/16/24 at 2:14pm the Admin stated, I do get the emails that say significant findings from radiology. If I see that email come through, I contact the DON and make sure she saw it and ask what it is about. If it is a night or weekend, I will still talk to the DON about it, and she will contact facility staff. The Admin stated, If there are significant or critical findings on any diagnostics, the physician should be notified in a timely manner- ASAP. It shouldn't be more than 2 hours once the nurse finds out that they try to notify the physician. 15 hours is not an acceptable time frame. The Admin stated he did not recall seeing a timeframe on the policy. The Admin stated the physician should always be notified if a resident complained of a significant increase in pain. The Admin stated it was important to notify the physician right away for changes in condition so that they could plan the next steps in the resident's care. The Admin stated if they did not notify the physician, the resident may not receive the appropriate care, they could have an adverse effect, they could be hospitalized , or it could lead to death. In a phone interview on 9/18/24 at 10:56am LVN L stated he worked PRN (as needed) at the facility, usually on weekends. LVN L stated it had been a while since he last worked there and he could not recall what date he worked there last. LVN L stated he remembered Resident #21's name but did not remember anything specific about her. LVN L stated if an x-ray was done, the results may have been faxed to the facility. LVN L stated that he thought had seen a couple of chest x rays come through on the fax before but did not recall that anyone got any significant x-ray results while he was on shift. LVN L stated if he ordered an x-ray and had not received a result after about a couple of hours, he would call the x-ray place and ask about it. LVN L stated that x-ray results could go straight to the resident's profile now. LVN L stated they could go into the results tab and see if the x-ray was resulted. LVN L stated there was not a pop up or anything to remind you to go look at the result. LVN L stated if he got a significant finding, he would call the doctor to let them know as soon as he got the result. LVN L stated in his orientation they went over the things you were supposed to notify the physician for. LVN L stated, I don't remember them saying when specifically, the doctor should be notified after receiving the results. LVN L stated if an x-ray was done on his shift and he had not gotten the result yet, he, as the off going nurse, reported it to the oncoming nurse who would keep an eye out for the result. LVN L stated there was also a piece of paper that stuff was written on to pass along to the next shift. In an interview on 9/18/24 at 2:10pm the DON stated that she never opened the email from the radiology company on 11/28/23. The DON provided a copy of the radiology company's print out of the details of Resident #21's x-ray that was done on 11/28/23. The print-out reflected that a SIGNIFICANT report was emailed to the DON and the Admin on 11/28/23 at 5:51pm. This print-out also reflected that a text message was sent to a phone number and a fax was sent to the facility's fax number with the x-ray findings on 11/28/23 at 5:51pm. The DON and the Admin stated that the fax number that the radiology company had was not the facility's fax number and they did not know why the radiology company had that number. The DON and the Admin also stated that they did not know who the phone number belonged to that the text message was sent to. An internet search on 9/20/24 revealed the fax number that the radiology company sent the result to had been associated with this facility and the phone number that the text message was sent to belonged to the person who was the DON at the facility at the time the contract with the radiology company was signed in 2022. Record review of Resident #21's Nursing Progress Notes reflected an entry by RN I dated 11/29/23 effective at 11:17am that stated, RP present, resident being transported per (non-emergent ambulance) stretcher report given to ambulance driver, and resident transported with paperwork and copy of DNR to ER, DON aware. [sic] Record review of Resident #21's Medication Administration Note reflected an entry by LVN J dated 11/29/23 effective 10:12pm that stated, admitted to hospital. Record review of Resident #21's Medication Administration Note reflected an entry by RN I dated 11/30/23 effective 11:23am that stated, At hospital. In an interview on 9/12/24 at 10:47am, the ME stated that Resident #21 passed away at home on [DATE] and that she ruled Resident #21's death as, Accident- Accidental fall/ complications of femur fracture, fall, dementia, hypertension, and COPD. The ME stated she did not do an autopsy, but rather reviewed all of Resident #21's medical records. Record review on 9/18/24 of the facility's radiology company contract that was signed on 2/8/22 reflected in part: SERVICES: 4. REPORTS The Radiologist will dictate a report to the attending physician for each examination. (The x-ray company) will provide a written copy of the written report to the community and to the attending physician. 6. WEB ACCESS (The x-ray company) agrees to provide the Community with direct access to patient records on the (x-ray company's) website. There was no part of the provided contract that discussed if, how, or when the facility would be notified of significant findings. Record review of this contract also revealed that it was signed by the current Admin on 2/8/22. Record review of the facility's Changes in Resident Condition Policy revealed in part: Compliance Guidelines: The resident, medical provider (MD/NP/PA) and resident representative or designated family member should be notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is important to facilitate consistency and continuity of care. Guidelines: 1. The resident, medical provider (MD/NP/PA) and resident representative or designated family member should be notified when there is: c. a significant change in the resident's physical, mental, or psychosocial status; 1) assess and document changes in; 2) provide assessment information to physician and 3) provide clear comprehensive documentation g. when laboratory, radiology or other diagnostic results fall outside the clinical reference ranges set by the contracted service provider or per physician orders. This policy did not indicate a timeframe for notifying the resident's physician or nurse practitioner after diagnostic results that fell outside of the clinical reference ranges were received. An Immediate Jeopardy was identified on 9/18/24 at 11:15am. The Admin was informed of the Immediate Jeopardy, given the Immediate Jeopardy template, and a Plan of Removal was requested on 9/18/24 at 2:06pm . The facility's Plan of Removal was accepted on 9/19/24 at 8:49pm. The facility's Plan of Removal included: [Facility] Plan of Removal F580 Notification of Changes in Condition Date: September 18, 2024 Corrective Action: Resident #21 who was admitted on [DATE] under hospice services for end-of-life care for diagnoses of Renal Failure, Liver Failure, Congestive Heart Failure, and Malignant Neoplasm of Left Breast sustained a witnessed fall on 11/25/23. Resident assessed by charge nurse and risk management report completed and MD/RP/hospice notification made. Non stat X-ray order obtained on 11/28/23 and positive fracture results received on 11/29/23 and reported to MD and hospice with hospice collaboration for RP notification. Resident discharged to hospital on [DATE]. Resident #21 is no longer an active resident within our community. Resident #21 was assessed and being monitored by the nurses prior to being sent to the hospital on [DATE]. Per hospital report, resident did not receive any treatment for fracture and was discharged home with family. Identification: All residents with change in condition may be at risk for the alleged deficient practice. Director of Nursing/Assistant Director of Nursing conducted an audit of all residents with recent (in last 60 days) to identify any changes in condition to include increased pain needs in order to ensure the MD/NP/PA have been notified and appropriate interventions were in place, as well as to ensure family representatives have been notified. Outcome: Date Completed: 9/18/24. Systematic Changes: The Regional Nurse (DCO) conducted an in-service to the Director of Nursing/Assistant Director of Nursing regarding the process for nurses to assess resident changes in condition to include pain and report any significant increase in pain and changes in condition identified to the MD/NP/PA. The nurse should ensure interventions are in place to address the resident's change in condition and/or pain needs and nurse should document in the electronic health record. Date Completed: 9/18/24. Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to next scheduled shift regarding: a. The process for ensuring that changes in condition have been identified to include pain and reported to MD/NP/PA. Orders given should be implemented as ordered and nursing should document in the electronic health record. b. Nurses will communicate during change of shift nursing report any changes in condition to include pain and ensure proper interventions are in place and notifications to the MD/NP/PA have been completed. c. Charge Nurses educated to follow HHSC guidance that indicates that the nurse should conduct a post fall assessment following the fall event. The nurse will continue ongoing monitoring of the resident following a fall event and should conduct follow up assessments upon any changes in condition identified. The nurse should then notify the medical provider upon identifying the change in condition or abnormal findings. The physician should be notified promptly upon identification of a change in condition and/or significant/critical abnormal diagnostic report. Typically, the notification will occur immediately but no more than two hours of being identified. The nurse will then attempt to contact the physician at minimum once per shift until the notificat[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #21) of 3 residents reviewed for diagnostic services. 1. The facility failed to immediately notify Resident #21's physician before 11/29/23 at 8:30am when Resident #21's radiology report dated 11/28/23 at 5:51pm revealed that Resident #21 had a displaced fracture of her left femur neck (top of the thigh bone at the hip) that occurred when Resident #21 fell in the facility's dining room on 11/25/23. On 9/18/24 at 2:06pm an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on 9/20/24 at 1:35pm, the facility remained out of compliance at a scope of isolated with a severity of no actual harm with the potential for more than minimal harm that was not Imediate Jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of a delay in treatment, decline in physical, mental, and/or psychosocial status, hospitalization, and even death. The findings included: Record review of Resident #21's face sheet reflected an [AGE] year-old female that was admitted to the facility on [DATE] with a primary diagnosis of Encounter for palliative care (care focused on improving quality of life for people with serious illnesses). Other pertinent diagnoses included congestive heart failure (the heart didn't pump blood effectively and could cause fluid buildup in the lungs), dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), inflammatory polyneuropathy (an auto immune attack on the peripheral nerves that can cause progressive muscle weakness, numbness, loss of reflexes, and pain or tingling in the arms, hands, legs, and feet), major depressive disorder, chronic kidney disease-stage 3 (mild to moderate kidney damage), dyspnea (shortness of breath), edema (swelling), muscle weakness, and muscle atrophy (wasting or loss of muscle tissue). There were no diagnoses related to liver damage or liver failure. Record review of Resident #21's admission MDS dated [DATE] reflected she had a BIMS score of 00 which indicated she had severe cognitive impairment. Record review of Resident #21's care plan dated 10/27/23 and revised on 10/30/23, 11/29/23 and 12/6/23 reflected in part: Focus: I have impaired cognitive function/dementia or impaired thought process r/t (Specify). Goal: I will (Maintain or improve) current level of cognitive function through the review date. Interventions/Tasks: Communicate with me, my family/caregivers regarding my capabilities and needs, Notify MD of any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Focus: I have a communication problem: Goal: I will be able to make basic needs known by (verbally/however able to express) on a daily basis through the review date. Interventions/Tasks: Anticipate and meet my needs. Notify MD PRN for changes in ability to communicate, potential contributing factors for communication problems, potential for improvement. Focus: I am at risk for falls r/t [left blank] Goal: I will be free from falls and/or will not experience significant injuries associated with falls through the next review date. Interventions/Tasks: Refer to therapy for screen and/or eval as indicated. Focus: Advanced care planning choices for end-of-life care: Hospice care elected. Goal: I will have my comfort, quality of life and dignity protected an honored through my next review date. In a phone interview on 9/12/24 at 10:05am Resident #21's family member stated that Resident #21 had a history of breast cancer and colon cancer but had received PET (Positron emission tomography) scans for at least the last 3 to 5 years prior to her admission to the facility that showed no cancer anywhere. Resident #21's family member stated that Resident #21 did not have any history of liver damage or liver failure and that Resident #21's primary care physician prior to going on hospice had told Resident #21 and her family member that her kidney disease was stable. Resident #21's family member stated that the reason Resident #21 went into the facility with hospice care was because Resident #21's dementia had progressed to the point that the family member could not take care of her at home anymore. Resident #21's family member stated that Resident #21 went back to the family member's house on 11/30/23 with hospice services because the emergency room physician and the surgeon told the family member that surgery for Resident #21's left hip fracture was not an option due to the resident now having kidney and liver failure. Resident #21 passed away at home on [DATE]. Record review of Resident #21's progress notes section in the facility's PCC system reflected an entry dated 11/25/23 at 2:38pm by RN I that stated, Resident stood up on her own out of her wheelchair in dining room, did not take any steps but lost her balance and CNA was standing near resident and resident went to the floor, landed on her left side, CNA who witnessed the fall cradled residents head and resident did not hit her head or face on the floor Resident checked for injuries, denies pain, and assisted by 3 staff members back into her wheelchair, DON, RP, and Medical provider notified. Resident taken to her room and vital signs taken and head to toe assessment completed. [sic] Record review of the facility's PCC assessments page for Resident #21 reflected an eINTERACT Change in Condition Evaluation that was entered on 11/25/23 in reference to Resident #21's fall in the facility's dining room on the same date that stated in part, Resident #21 had no complaints of pain. Resident [#21] had a witnessed fall with neuro checks intact, moves all extremities, and no s/s of injuries, skin checked for discoloration none noted at this time [sic]. This document reflected that the physician was notified of Resident #21's fall on 11/25/23 at 2:45pm and the physician's recommendation was to refer Resident #21 for a physical therapy evaluation. In an interview on 9/11/24 at 3:50pm, the DON stated, We did not do x-rays at the time [of the fall] because when I looked at the camera, she was self-propelling in the dining room. She was shaking a doorknob and kind of slid out of her chair onto the floor. She did not actually stand and fall. She did not have any bruising at that time. We got an x-ray on the 28th (11/28/23). I don't remember why or what her signs and symptoms were. With hospice patients, hospice won't order x-rays, so we contacted our doctor instead of the hospice physician and that's why there was a delay from the complaint of pain on the 27th (11/27/23) to the order on the 28th (11/28/23). In an interview on 9/13/24 at 12:48pm, CNA M stated, On 11/25/23, Resident #21 was in the dining room toward the kitchen washroom area. I was passing by taking people out of the dining room. I saw her getting up off the wheelchair and standing. Once I saw her taking some steps and was unbalanced, I knew she was going to fall so I sprinted over there to try to catch her. It was kind of a slow fall. She was not quite on the floor when I got to her, so I made sure she did not hit her head. When she was on the floor, she was kind of on her left side. Two other people saw it as well and came in to assist me to get her back to her chair. She said she was in pain after that. I can't remember if she said her arm or her hip, but she was saying, ow- it hurts, it hurts. She was just kind of whimpering and saying she hurt when she was assisted back into the wheelchair. Record review of Resident #21's Orders reflected a left shoulder and hip/pelvis x-ray ordered by RN K on 11/28/24 at 11:30am. Record review of Resident #21's printable view progress notes dated 11/29/23 at 8:34am reflected an entry by RN I that stated, Xray report from Xray of 11/28/23 reviewed and reported to medical provider left shoulder x ray showed no acute fracture, RP states she will think about the situation, but shows grossly displaced femoral neck fracture of left hip, acute fracture. Medical provider recommends send resident too [sic] ER (Emergency Room) for evaluation of left hip fracture. DON notified. And RP notified and will think about whether she wants notify Nurse when she makes a decision on sending the resident sent out to ER, states she will call back to notify this facility. Call out to the hospice company to notify of positive left hip fracture, left msg to have hospice return my call. [sic] Record review of the facility's PCC assessments page for Resident #21 reflected an unsigned eINTERACT Change in Condition Evaluation that was dated 11/29/23 and reflected the situation being reported was Trauma (fall related or other) and that Resident #21 had new pain, left hip pain/left iliac crest (rear)/Left trochanter (hip) and intensity of pain 2 of 10. In the area for observation and evaluation summary, the author documented, Results of x ray to hip positive for Grossly displaced femoral neck fracture of left hip with no discoloration to area. Resident does have pain on left hip, with pain medication. Medical provider notified and recommends to send resident out to ER for evaluation, DON notified of Results of left hip X RAY and RP notified states since resident is hospice, she will need to decide whether she wishes to send resident out to ER, will notify nurses of her decision [sic]. This document also stated that Resident #21's physician was notified on 11/29/23 at 8:40am and the physician recommended Resident #21 be taken by non-emergent transfer ambulance for evaluation of left hip fracture to the ER. In an interview on 9/11/24 at 3:56pm, the DON stated, If there is a significant finding for an x-ray, I receive an email and they call the facility within, I think, 24 hours. I received the email at 5:51pm (on 11/28/23). Even if I was gone for the day, I would check my email from home. I may have been out with the flu or COVID at that time, but I remember calling the facility that evening. I can't say why the physician was not notified until 8:30 the next morning or why the nurse didn't document anything. The physician and RP should have been notified that evening. A lot of the longer tenure nurses will want to notify the hospice doctor before the facility doctor because they are hospice, but we don't have documentation of that either. If the physician and RP are not notified, it could lead to negative outcomes including untreated pain or worsening of a fracture. The physician and RP should be notified immediately when critical results are received. The DON did not state who she talked to when she called the facility on 11/28/23 about the x-ray results. In a telephone interview on 9/13/24 at 10:21am a supervisor for the facility's contracted radiology company stated that the result of the left shoulder and hip/pelvis x-ray was automatically delivered by email to the facility's DON and administrator on 11/28/23 at 5:51pm. The supervisor stated that the result was also automatically faxed to the facility's fax number on record on 11/28/23 at 5:51pm, but that it failed. The supervisor stated there was no documentation that the radiology company called the facility to report the significant findings of the x-ray. In a telephone interview on 9/13/24 at 11:00am the MD stated he would expect for the physician or nurse practitioner to be notified of any critical/significant results with 30-45 minutes. The MD stated he did not know if Resident #21's outcome would have been different if he had been notified of her broken femur when the x-ray was resulted on 11/28/23 at 5:51pm. The MD stated if for some reason the facility was unable to contact either the NP or the MD, they should just go ahead and send the resident out to the ER. The MD stated that when Resident #21 was treated for 10 of 10 pain specifically to her left leg and shoulder on 11/27/23 following a fall on her left side on 11/25/23 he or nurse practitioner should have been notified. The MD stated, What we know of hip fractures in older adults, we need to intervene sooner rather than later because being in bed for three days, especially if they are in pain and probably not eating or drinking well, it can lead to multi organ failure. If we had known about the fracture and intervened earlier, she may have lived a little longer. The MD stated that it was ultimately a hospice decision to x-ray a hospice patient, but if she had not been a hospice patient, it would have been prudent to do an x-ray at the time of the fall. In an interview on 9/13/24 at 1:11pm the ADON stated for critical findings, the lab or radiology would call the facility and would ask for the nurse of that specific resident. The nurse would talk to them and get the results. After the nurse received the critical or significant finding information, he/she would then call the doctor and see if there were any new orders. The ADON stated, We call the doctor immediately when we have critical results. The ADON stated, That I know of there isn't a specific policy in writing about when to notify the doctor of critical results. In an interview on 9/16/24 at 11:12am, RN K stated if there was an abnormal finding on an x-ray, the radiology company posted the results on the website. RN K stated she did not think the facility got called if there were significant findings. RN K stated she thought that once the results got posted, the facility doctor looked at the results and it went from there. RN K stated she did not recall any time when the DON or ADON went to her and said that there was an abnormal x-ray result and for her to notify the physician. RN K stated if the nurse found something (a significant finding) before the doctor did, then the nurse would call the doctor immediately. RN K stated if the nurse was not able to contact the doctor, he/she was to contact the DON to let her know so that she could follow up. RN K stated the x-ray technician would not tell the nurse if they saw something abnormal on the x-ray. RN K stated that sometimes x-rays would result right away, but sometimes they took a very long time. In a telephone interview on 9/16/24 at 11:48am LVN J stated when an x-ray was done, the nurse would have had to look for the results and that there was no flag or anything to let the nurse know that the results were posted. LVN J stated if she was going off shift, she would pass it on to the next shift to look for the results. LVN J stated they would not be notified by the radiology company. LVN J stated sometimes the x-ray technician would let them know if something did not look right and to keep an eye out for the report. LVN J stated if she pulled up an x-ray report and something looked abnormal or bad, she would notify the physician right away- as soon as she saw the result. LVN J stated she did not know if anyone at the facility got notified automatically of results. LVN J stated that she worked at the facility until March 2024 and had been there for about a year. LVN J stated they discussed notification of changes and physician notification almost every day and had once a month in-service on various topics. In an interview on 9/16/24 at 12:24pm, the DON stated, At that time (11/28/23) when abnormal or critical x-rays were received, the facility would receive a phone call with the results. I would also get an email for significant findings. Normally, if I wasn't at the facility, I would call to make sure the nurse knew of the findings. Let's say I didn't see the email or get the email; the x-ray people would call the facility and we could get into the portal and print out the x-ray results. X-ray will call, but sometimes they don't call until the next day. If it was the next day, it was like a follow up call when they'd ask if we saw it. If the facility is notified of an abnormal result (for hospice) it would depend on the nurse whether the primary doctor or hospice would get notified first, but they would both be notified. The nurse would need to notify the doctor as soon as they found out about it. In reference to (Resident #21's) x-ray result, I got the email on 11/28/23 at 5:51pm. I was not here (at the facility) at the time, and I don't remember if I called the facility or not. The DON stated that the floor nurse would have had to go into the portal to see if the x-ray result was there. The PCC system did not flag or alert when an x-ray was resulted, the nurse would have to check. The DON stated if the x-ray was not resulted during the day shift, the day shift nurse would pass on to the night shift nurse to look out for the result. If for some reason the night shift nurse did not get the result, then the day shift nurse would follow up the next morning. The DON stated, In general, if there was a critical or significant finding, the physician should have been notified right away. Notification 15 hours later is generally not acceptable. There may be times when that would be ok, but in this particular case, no. The DON stated, She (Resident #21) wasn't x-rayed the day of the fall because she didn't display any signs or symptoms of pain; not even when they were getting her off the floor initially. The DON stated it was important to notify the physician of any significant change in condition or results of diagnostics so that they could provide the best quality of care for the resident. The DON stated if the physician was not notified of changes or diagnostic results, the resident's quality of care could have been affected, the resident may not have gotten needed treatment, services, or medication, the resident could have been hospitalized , or it could have even led to death. The DON stated, The policy does not have a specific time frame for notification. The DON stated when a physician was notified of results or a change of condition, documentation included dated and time of notification of provider and RP and any new orders. In an interview on 9/16/24 at 2:14pm the Admin stated, I do get the emails that say significant findings from radiology. If I see that email come through, I contact the DON and make sure she saw it and ask what it is about. If it is a night or weekend, I will still talk to the DON about it and she will contact facility staff. The Admin stated, If there are significant or critical findings on any diagnostics, the physician should be notified in a timely manner- ASAP. It shouldn't be more than 2 hours once the nurse finds out that they try to notify the physician. 15 hours is not an acceptable time frame. The Admin stated he did not recall seeing a timeframe on the policy. The Admin stated the physician should always be notified if a resident complained of a significant increase in pain. The Admin stated it was important to notify the physician right away for changes in condition so that they could plan the next steps in the resident's care. The Admin stated if they did not notify the physician, the resident may not receive the appropriate care, they could have an adverse effect, they could be hospitalized , or it could lead to death. In a phone interview on 9/18/24 at 10:56am LVN L stated he worked PRN (as needed) at the facility, usually on weekends. LVN L stated it had been a while since he last worked there and he could not recall what date he worked there last. LVN L stated he remembered Resident #21's name but did not remember anything specific about her. LVN L stated if an x-ray was done, the results may have been faxed to the facility. LVN L stated that he thought had seen a couple of chest x rays come through on the fax before but did not recall that anyone got any significant x-ray results while he was on shift. LVN L stated if he ordered an x-ray and had not received a result after about a couple of hours, he would call the x-ray place and ask about it. LVN L stated that x-ray results could go straight to the resident's profile now. LVN L stated they could go into the results tab and see if the x-ray was resulted. LVN L stated there was not a pop up or anything to remind you to go look at the result. LVN L stated if he got a significant finding, he would call the doctor to let them know as soon as he got the result. LVN L stated in his orientation they went over the things you were supposed to notify the physician for. LVN L stated, I don't remember them saying when specifically, the doctor should be notified after receiving the results. LVN L stated if an x-ray was done on his shift and he had not gotten the result yet, he, as the off going nurse, reported it to the oncoming nurse who would keep an eye out for the result. LVN L stated there was also a piece of paper that stuff was written on to pass along to the next shift. In an interview on 9/18/24 at 2:10pm the DON stated that she never opened the email from the radiology company on 11/28/23. The DON provided a copy of the radiology company's print out of the details of Resident #21's x-ray that was done on 11/28/23. The print-out reflected that a SIGNIFICANT report was emailed to the DON and the Admin on 11/28/23 at 5:51pm. This print-out also reflected that a text message was sent to a phone number and a fax was sent to the facility's fax number with the x-ray findings on 11/28/23 at 5:51pm. The DON and the Admin stated that the fax number that the radiology company had was not the facility's fax number and they did not know why the radiology company had that number. The DON and the Admin also stated that they did not know who the phone number belonged to that the text message was sent to. An internet search on 9/20/24 revealed the fax number that the radiology company sent the result to had been associated with this facility and the phone number that the text message was sent to belonged to the person who was the DON at the facility at the time the contract with the radiology company was signed in 2022. Record review of Resident #21's Nursing Progress Notes reflected an entry by RN I dated 11/29/23 effective at 11:17am that stated, RP present, resident being transported per (non-emergent ambulance) stretcher report given to ambulance driver, and resident transported with paperwork and copy of DNR to ER, DON aware. [sic] Record review of Resident #21's Medication Administration Note reflected an entry by LVN J dated 11/29/23 effective 10:12pm that stated, admitted to hospital. Record review of Resident #21's Medication Administration Note reflected an entry by RN I dated 11/30/23 effective 11:23am that stated, At hospital. In an interview on 9/12/24 at 10:47am, the ME stated that Resident #21 passed away at home on [DATE] and that she ruled Resident #21's death as, Accident- Accidental fall/ complications of femur fracture, fall, dementia, hypertension, and COPD. The ME stated she did not do an autopsy, but rather reviewed all of Resident #21's medical records. Record review on 9/18/24 of the facility's radiology company contract that was signed on 2/8/22 reflected in part: SERVICES: 4. REPORTS The Radiologist will dictate a report to the attending physician for each examination. (The x-ray company) will provide a written copy of the written report to the community and to the attending physician. 6. WEB ACCESS (The x-ray company) agrees to provide the Community with direct access to patient records on the (x-ray company's) website. There was no part of the provided contract that discussed if, how, or when the facility would be notified of significant findings. Record review of this contract also revealed that it was signed by the current Admin on 2/8/22. Record review of the facility's Changes in Resident Condition Policy revealed in part: Compliance Guidelines: The resident, medical provider (MD/NP/PA) and resident representative or designated family member should be notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is important to facilitate consistency and continuity of care. Guidelines: 1. The resident, medical provider (MD/NP/PA) and resident representative or designated family member should be notified when there is: g. when laboratory, radiology or other diagnostic results fall outside the clinical reference ranges set by the contracted service provider or per physician orders. This policy did not indicate a timeframe for notifying the provider after diagnostic results that fell outside of the clinical reference ranges were received. An Immediate Jeopardy was identified on 9/18/24 at 11:15am. The Admin was informed of the Immediate Jeopardy, given the Immediate Jeopardy template, and a Plan of Removal was requested on 9/18/24 at 2:06pm. The facility's Plan of Removal was accepted on 9/19/24 at 8:49pm. The facility's Plan of Removal included: [Facility] Plan of Removal F777 Radiology/Diag. Services Ordered/Notify Results Date: September 18, 2024 Corrective Action: Resident #21 who was admitted on [DATE] under hospice services for end-of-life care for diagnoses of Renal Failure, Liver Failure, Congestive Heart Failure, and Malignant Neoplasm of Left Breast sustained a witnessed fall on 11/25/23. Resident assessed by charge nurse and risk management report completed and MD/RP/hospice notification made. Non stat X-ray order obtained on 11/28/23 and positive fracture results received on 11/29/23 and reported to MD and hospice with hospice collaboration for RP notification. Resident discharged to hospital on [DATE]. Resident #21 is no longer an active resident within our community. Resident #21 was assessed and being monitored by the nurses prior to being sent to the hospital on [DATE]. Per hospital report, resident did not receive any treatment for fracture and was discharged home with family. Identification: All residents who have abnormal X-ray results may be at risk for the alleged deficient practice. Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any abnormal x-rays within the last 60 days to ensure the MD and family representatives have been notified and appropriate interventions are in place and prescribers orders have been carried out as ordered. Outcome: No negative outcomes identified. Date Completed: 9/18/24. Systematic Changes: The Regional Nurse (DCO) conducted an in-service to the Director of Nursing/Assistant Director of Nursing regarding the process for ensuring that abnormal x-ray have been identified, x-ray portals are being checked during shift to identify pending results, and the results are reported to the medical provider, orders provided should be implemented as ordered and nursing should document in the electronic health record the notification of abnormal x-ray results to the MD/NP/PA as well as any prescribed orders. Date Completed: 9/18/24. Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to next scheduled shift regarding: a. The process for ensuring that abnormal x-rays have been identified, x-ray portals are being checked once in first half of shift and once in second half of shift to identify pending results, and the results are reported to the medical provider upon receipt of abnormal x-ray findings, orders provided should be implemented as ordered and nursing should document in the electronic health record the notification of abnormal x-ray results to the MD/NP/PA as well as any prescribed orders. b. If the x-ray company is unable to reach the nursing staff on duty, they will place a call to the Director of Nursing/Administrator or Regional Nurse DCO (contact information provided) so that timely notification to the MD/NP/PA. This has been communicated to the X-ray company and confirmed by them via email and telephone call. c. Charge Nurses will report abnormal x-ray findings to DNS/ADNS via in person or telephonic communication. d. Nurses will communicate during change of shift nursing report any pending x-rays results or changes in condition such as increased pain needs and ensure proper interventions are in place and notifications to the MD/NP/PA have been completed. e. Charge Nurses educated to follow HHSC guidance that indicates that the nurse should conduct a post fall assessment following the fall event. The nurse will continue ongoing monitoring of the resident following a fall event and should conduct follow up assessments upon any changes in condition identified. The nurse should then notify the medical provider upon identifying the change in condition or abnormal findings. Date Completed: 9/18/24. Monitoring: DNS/ADNS (Director of Nursing / Assistant Director of Nursing) will review during the clinical meeting (5-7 days per week) abnormal x-ray results, both pending and resulted in order to validate appropriate interventions are in place, proper follow up and notifications to MD/NP/PA has been made in order to ensure patient care needs are met, and documentation is noted within the medical record. Date initiated: 9/18/24 & Ongoing. Administrator and Director of Nursing conducted an Ad Hoc QAPI meeting with the Medical Director on 9/18/24 to review plan of removal / immediate corrective action plan implemented. Date Completed: 9/18/24. The facility will conduct a monthly QAPI meeting to review the status and compliance notification to MD/NP/PA abnormal x-ray results, ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is in noted within the E.H.R. Findings of audits and status of compliance will be reviewed to the Administrator and the QAPI committee during the monthly meetings for the next 2 -3months. Verification of the facility's Plan of Removal consisted of the following: Interviews with licensed staff (included both shifts) in person and by telephone on 9/20/24 included: 11:26am - LVN D 11:36am - LVN P 11:46am - LVN Q 12:00pm - ADON 12:26pm - LVN R 12:35pm - LVN S 12:48pm - NAC 1:00pm - DCE 1:04pm - RN T All staff interviewed stated the physician and responsible party are to be notified immediately anytime there is a change in a resident's condition, change in pain level, or critical lab/x-ray results. All staff stated that they were to notify the DON if they were having issues with getting x ray results. All staff stated the change in condition or critical result is to be documented in the electronic health record, as well as who was notified and when. All staff stated any new orders are to be entered as soon as they are received, and if it was an order for physical or occupational therapy, they would go tell physical therapy or occupational therapy and would place that information on the 24 hour report. All staff stated falls are to be documented in the progress notes and ongoing resident assessments should be done to include assessing for pain. All staff stated any change in resident condition or pending results for labs or x rays were to be passed on to the next shift during report and documented on the 24 hour communication report in PCC. All staff stated they received hand-outs with the information that was covered in the in-services. The Admin stated that he contacted the radiology company about notification of significant reports and requested that significant reports not be em[TRUNCATED]