**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the residents received adequate supervision to prevent accidents for one (Resident #1) of seven residents reviewed for elopements. The facility failed to provide adequate supervision for Resident #1 for one hour and 20 minutes. He was last seen on 06/01/23 at 6:30 am and after that, the resident eloped from the facility and was observed by a concerned citizen who called Law Enforcement because Resident #1 was at a car wash located along a busy six lane street and four way cross intersection and 0.4 miles away from the facility. Resident #1 was returned to the facility on [DATE] at 7:52 am by Law Enforcement. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 06/01/23 at 6:30 AM to 06/06/23. The Noncompliance was identified as PNC because the facility staff were unaware Resident #1 had eloped from the facility. The Immediate Jeopady was determined to have been removed on 06/06/23 due to the facility's implemented actions that corrected the non-compliance of re-educating staff about elopement prevention and response, elopement risks and alarm management of the access codes, prior to the beginning of the HHSC investigation on 08/16/23. The Staff confirmed when interviewed they were adequately trained about the prevention and response of resident elopements. This failure could place residents at risk for accidents, falls and serious injury resulting in a decreased psycho-social well-being, physical decline or death. Findings included: Record review of Resident #1's Order Summary Report dated 08/17/23 revealed a [AGE] year-old male who admitted to the facility 08/01/2022 with diagnoses other seizures, essential hypertension, cognitive communication deficit, cardiomegaly (enlarged heart), convulsions (seizures), need assistance for personal care, DM II, dementia, psychotic disturbance, mood disturbance and anxiety and took carvedilol (blood pressure), clonidine (Blood pressure), donepezil (Memory loss), insulin glargine solution (diabetes), levetiracetam (seizures), losartan (blood pressure), metformin (diabetes), spironolactone (blood pressure). Record Review of Resident #1's admission MDS assessment dated [DATE] revealed he had a BIMS score of 06 (severe impaired cognition) and no wandering behavior exhibited, supervision with one person assistance with walking, balance not steady when walking, no upper extremity impairment and no lower extremity impairment and no mobility assist with walking. Record Review of Resident #1's Discharge MDS assessment dated [DATE] revealed he had a Staff Assessment score of 02 (moderate impaired cognition) no wandering behavior exhibited, supervision with one person assist with walking and he discharged to another nursing home. Record review of Resident #1's Care plans dated 08/09/23 revealed, care plans for: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Oxygen dependent, Shortness of Breath, Hypertension, Diabetes Melilotus, Anti-psychotic monitoring, Impaired Vision, falls, communication problems, potential deficit due to memory loss/dementia, wander risk (Interventions: identify pattern of wandering, is wandering purposeful, aimless, or escapist, is resident looking for something, does it indicate a need for more exercise, intervene as appropriate .is the resident exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.Monitor for fatigue and weight loss .provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes) and hearing deficient . and on 06/01/23 care plan for actual elopement. Record review of Resident #1's Nurse Progress Notes from 08/09/22 to 05/31/23, revealed no documented evidence Resident #1 had eloped or attempted to elope, but at times wandered to the wrong hall from where his room was located and was easy to re-direct to right hall. Record review of Resident #1's Elopement Risk Assessment Version 2 dated 02/01/23 revealed a risk score of 12 (moderate risk) out of 15 points, for elopement risk, because he was not bedfast, and not on a secured unit and ambulated without assistance. Record review of the facility's Elopement Drills dated 03/24/23, 04/12/23 and 05/22/23 were conducted with RN's, CNA's, LVN's, Social Worker, Housekeepers, Laundry aides, Receptionist, Dietary, Therapists, Medical Records, Medication aides, Receptionist, Activities Director, Maintenance Director. Record review of the Facility's Provider Investigative Report dated 06/01/23 revealed Resident #1 had dementia without behavioral disturbance, mood disturbance and anxiety, cognitive communication deficit. Resident #1 said he went for a walk on the morning 06/01/23. At 7:40 am the resident was accompanied by LE. The incident occurred during shift change and Resident #1 had no adverse effects. In-service education on the elopement policy and prevention was initiated and completed. The resident was put on 1:1 observation until transferred to a facility with a secured unit. Completed an elopement audit on all residents and updated care plans. Had an outside provider come out to reassure all doors were functioning properly. Statement from CNA A revealed the resident was in bed all night and the last time Resident #1 was seen was at 6:00 am in bed. Findings: Confirmed. Record review of Resident #1's Police Report dated 06/01/23 revealed: Primary incident code: Welfare Check or concern 06/01/23 07:27:16 am Resident #1 IS THERE (at the Car Wash) AND IS GOING AROUND AND TRYING TO GET INTO THE BUILDING . 06/01/23 07:27:39 am Reporter IS CONCERNED ABOUT THIS GENTALMAN [sic] . 06/01/23 07:27:55 am LE Dispatch . 06/01/23 07:28:05 am B\M - 70'S - BLK SWEAT PANTS THIN JACKET . 06/01/23 07:28:14 am Reporter IS STILL THERE . 06/01/23 07:28:30 am Subject KEEPS SAYING HE LIVES THERE . 06/01/23 07:38:12 am Arrived .06/01/23 07:45:17 am Leaving Scene (Location: Healthcare Center) . 06/01/23 07:52:31 am Male was lost, possibly has dementia, lives at the Nursing Home . 06/01/23 07:52:47 am taken back to the nursing home. Record review of Resident #1's Progress Noted dated 06/01/23 by LVN F revealed, The patient had a head-to-toe assessment on Resident #1, the patient has no injury body anywhere .Vitals were taken (temperature 97.2, bp 138/89 .Sats 97 room air). Record review of Resident 1's Event Nurses Note 12 hr. - Elope or Attempt - Version 2 dated 06/02/23 at 11:56 am by the Former DON revealed, Resident #1 lying in bed with eyes closed and resting. CNA remained at bedside to provide 1:1 supervision .Elopement: Resident #1 exited front entrance, missing for approximately 2 hours and 20 minutes, resident observed .4 miles from the facility at the car wash, resident is independent with ambulation and expressed no desire to leave facility, no injures, vitals checked, and no new physician's orders. The resident stated he was just taking a walk. The Doctor was called on 06/01/23 at 8:10 am and the responsible party was notified on 06/01/23 at 8:10 am. Interventions included: 1:1 supervision and assisting family with placement in a secured unit. The resident was independent with all ADL's, no environment/equipment factors and yes to cognitive impairment. The facility took the following action to correct the non-compliance on 06/06/23: Record review of Resident #1's Progress Note dated 06/01/23 by DON revealed, Continue monitoring resident for exit seeking behaviors. 1:1 supervision until accepted at referred facility. Record review of Resident #1's Elopement Risk Assessment Version 3 dated 06/01/23 revealed a risk score of 22 (high risk) out of 23 points, for elopement risk, because he eloped on 06/01/23. Record review of the Schedule Sheets dated 06/01/23 and 06/02/23 revealed CNA's and nurses who completed the 1:1 monitoring of Resident #1. Record review of Resident #1's Former Social Worker progress note dated 06/02/23, revealed, SW followed up resident accepted to both facility's resident will be admitting to Nursing Facility per admissions coordinator. SW awaiting admission follow up with the time the resident will arrive. Interview on 08/16/23 at 10:00 am, the Maintenance Director stated after Resident #1 eloped June 2023, the facility's doors were checked by their Outside Provider, and they said there were no issues with the doors, alarms, or keypads malfunctioning. He stated the facility requested the outside Provider change how the door alarms and keypads operated. He stated the staff used to be able to reset the door alarms remotely to stop the alarm from ringing, but now when the door alarms sounded off, they did not stop ringing after so many seconds. He stated the staff had to go to the door triggering the alarm by resetting it with the code and the staff also had to look around for any residents. Interview on 08/17/23 at 4:23 pm, the Maintenance Director stated the facility had 9 exit doors which had keypads and panic bars, but two of the doors were in the kitchen and the residents had no access to. He stated none of the visitors/family members had the pass codes to enter and exit and only the staff did. He stated he changed the keypad codes monthly and when needed and would continue to inspect the doors and alarms weekly. Interview on 08/16/23 at 10:50 am, LVN B stated Resident #1 eloped away from the facility June 2023 and he returned uninjured and shortly after he was transferred to another facility. She stated Resident #1's cognition was A/O (alert and oriented) x 2, very confused with short term memory loss and needed redirection at times because he forgot where his room was at times. She stated they were in-serviced on how to operate the door alarms because they used to stop sounding off after the alarm was triggered, but now they had to go to the door and press the keypad to get the alarm to reset. She stated they were also trained on monitoring the residents. She stated if a resident was suspected of being missing, they needed to do an immediate count of the residents. She stated the elopement protocol was for all staff to know about the facility's elopement procedures, not just nursing to alert nursing and pay attention to their surroundings to ensure the residents were not exit seeking. Interview on 08/16/23 at 5:37 pm, the Administrator stated Housekeeper/Floor Tech C was the last person who saw Resident #1 by the 600 Hall water fountain around 6:30 am, then an hour and half later he was returned by LE. She stated HSK D alerted Treatment Nurse E about LE being outside with Resident #1 around 7:50 am. She stated Treatment Nurse E spoke to LE and assessed Resident #1 after he returned to the facility, and he was fine and then they started the 1:1 monitoring with him until he discharged to a secured unit facility. She stated the former DON interviewed the staff and got all of their statements about his elopement. She stated they in-serviced the staff and had monthly elopement drills; the nurses did the elopement risk assessments for all the residents; weekly door checks were conducted, and they had a QA meeting about the incident. She stated the door alarm used to sound off after 15 seconds of the panic bar being pressed and stop ringing but now when the door alarm sounded off it did not stop until a staff physically went up to the keypad to put in the code to turn the alarm off and look around the area for residents. She stated they were not sure how Resident #1 eloped but suspected it may have been a visitor thinking he was a visitor but that was never confirmed. She stated Resident #1 had not been exit seeking or ever eloped from this facility or made statements of wanting to leave this facility in the past. She stated all of the facility's doors locked and had panic buttons that would allow the doors to open and the alarm to sound off for a few seconds and stop and they also had a remote way to reset the door locks. Interview on 08/16/23 at 6:07 pm, LVN F stated Resident #1 was not her resident, but she saw him in passing and he walked without assistance and wandered to the wrong hall at times. She stated he was never exit seeking or made statements of wanting to leave and added there were no problems with the door alarms and locks not working. She stated she heard about Resident #1 eloping this past June 2023. She stated they had a training on how to reset the door alarms and how to go to the door and press the code to the keypad and check outside to ensure no residents had exited from the facility. Interview on 08/16/23 at 6:22 pm, LVN G stated she was being trained by LVN B and was Resident #1's nurse working the night of 05/31/23. She stated she made rounds every two hours and did not know what time Resident #1 left the building and had made checks of the residents every two hours and there were not any issues with Resident #1 trying to elope. She stated there were no problems with the alarms going off on 05/31/23 and of 06/01/23. She stated she was not sure when Resident #1 returned to the facility because she got off work at 7:00 am. Interview on 08/17/23 at 9:00 am, Housekeeper/Floor Tech C stated on 06/01/23 she last saw Resident #1 around 6:30 am in the hallway by his room and the hall water fountain. She stated Resident #1 was not near an exit door and had on jogging pants and a shirt and Resident #1 said hello and she said hello back. She stated she went to get the floor cleaning supplies to start cleaning the floors and further in the day she heard Resident #1 eloped from the facility. She stated prior to 06/01/23, Resident #1 was not exit seeking and walked around without assist. She stated after Resident #1 eloped; the DON asked her what she knew about it, and she wrote a statement. She stated afterwards they had an elopement training by their supervisor about what the elopement code was and what to do if a resident was missing. She stated they now the door alarm would continue to sound off until they went to the door that triggered to press the keypad code. She stated the keypad code was changed once monthly. Interview on 08/17/23 at 11:09 am, LVN H stated Resident #1 was not exit seeking in the past and said worked the day he eloped 06/01/23 but did not hear the door alarms ringing and was unaware he eloped because she got off work at 7:30 am. She stated when she returned to work the next day, 06/02/23 at 7:00 pm, she heard Resident #1 had gotten out of the building and was brought back. She stated Resident #1 was getting 1:1 monitoring in rotation by the CNAs, and someone came to check the doors and locks. She stated on 06/02/23 Resident #1 was discharged to a secured unit facility. She stated after the incident she was trained on the new way they checked the doors and alarms. She stated they looked at the main panel and went to the door triggering the alarm codes labeled (1-7 doors), to make sure none of the residents were outside. She stated after she pressed the code on the keypad next to the exit door to stop the alarm, she then pressed the code to the keypad at the nurse's station. She stated before the incident the alarm would stop ringing after a few seconds but not any longer until the code was pressed. She stated they also did a couple of elopement in-services on the policy and procedures with how to proceed if they thought a resident eloped. She stated if a resident was to elope, they could fall or get injured. Interview on 08/17/23 at 12:30 pm LVN I stated Resident #1 used to be a resident at the facility, he had dementia and on occasion walked to the wrong hall from where his room was located, and he had to be redirected. She stated she started her shift on 06/01/23 at 7:00 am and was not aware he was missing and there were no alarms ringing when she arrived. She stated on 06/01/23 around 8:00 am he was dropped off by the police officers and that was when it was known that Resident #1 was gone. She stated Treatment Nurse E told them LE found Resident #1 down the street. She stated not too long after that he was transferred to secured unit. She stated Resident #1 was independent and confused about when church services were and where his room was and never exit seeking. She stated she was surprised he walked out and felt Resident #1 did not intentionally leave the facility. She stated Resident #1 had dementia and added after the incident they had in-service trainings about making sure the door alarms were reset and to go look to see what was going on to see what triggered the door alarm to go off, then reset it. She stated if a resident eloped, they could fall because the facility was right next to a busy street and a lot of things could happened, the resident could get lost or hit by a car. She stated the resident may not be found and could die, be in danger and could get dehydrated. Interview on 08/17/23 at 1:14 pm, LVN B stated she worked a few hours on 06/01/23 when Resident #1 eloped and the last time she saw Resident #1 was 10:00 pm and he his usual self, confused in his room and not exit seeking. She stated she got off work around 12:00 am because it was not her shift and there were three other nurses there that night. She stated after Resident #1's elopement the former DON came in on a Saturday 06/03/23 and spoke to all the staff; and explained to the entire staff it was everybody's responsibility to watch the doors. They went over the correct procedures of going to the door when the door alarm sounds off, to check to see if a resident was seen. She stated the DON said if a resident eloped they needed to do a count of the residents and to make a circle around the building, contact LE, the Administrator and DON. She stated after Resident #1 eloped she worked the 7:00 pm - 10:00 pm as a sitter and did 1:1 monitoring of Resident #1 who was mostly asleep and watched tv and was not exit seeking or made statements of wanting to leave. She stated CNA J did 1:1 monitoring of Resident #1 as well and later that day he was taken to another facility. She stated they made it clear they had to go to the door and press the code to let people out and could no longer reset the door alarm remotely. Interview 08/17/23 at 1:30 pm, CNA J stated she was not Resident #1's aide but saw him in passing the night of 05/31/23 he was in his room with the door open and in his bed asleep. She stated when she got off work 06/01/23 at 7:00 am she did not see him walking around anywhere and did not know he had eloped until she returned to work later that day, 06/01/23. She stated she heard Resident #1 had eloped and was getting 1:1 sitter monitoring. She stated Resident #1 was transferred to another facility with a secured unit. She stated after Resident #1's elopement she was trained on elopement and the new way to use the door system and by making sure residents were in their rooms and if there was a reason to believe the resident was missing they needed to check the rest room and outside, and do head counts. Interview on 08/17/23 at 1:44 pm CNA K stated Resident #1 eloped and LE found him close to the car wash. She stated Resident #1 did not show any signs of eloping or exit seeking but after he eloped, they had elopement trainings to prevent that from happening again. Interview 08/17/23 at 2:35 pm, the ADON stated they had no residents who were exit seeking or had eloped but heard about Resident #1 elopement and he was transferred to another facility. She stated if a resident was to be exiting seeking, they would have to be transferred to another facility with a secured unit. She stated they had a door alarm system and had to monitor the residents every two hours. She stated they had elopement trainings and was told if a resident was exit seeking or actually eloping, and they were not able to re-direct the resident she would stay with the resident and alert other staff to assist with getting the resident back into the facility. She stated personally she could not walk away from the resident and would just follow their elopement policy. She stated if a resident eloped they could get hit by a car or got lost. Interview on 08/17/23 at 3:37 pm, the Medical Director stated it was reported to him Resident #1 eloped and returned to the facility not injured, a few months ago and he did not need to go to the hospital. He stated Resident #1 was transferred to a secured unit and added after Resident #1 eloped they had a Quality Assurance meeting to further plan to prevent any other residents from eloping. He stated they were not sure how he got out and added the staff were pretty competent to keep an eye on the residents. He stated his expectation was for staff to ensure the doors were locked to prevent any further elopements and added all staff were responsible for ensuring the residents did not elope. Interview on 08/17/23 at 4:53 pm, the Administrator stated when Resident #1 eloped on 06/01/23, none of the staff were aware Resident #1 was missing until LE brought him back to the facility. She stated her expectations for preventing elopements was for the DON or designee to ensure the nurses completed the admission elopement risks. She stated the DON or designee needed to review the elopement assessments weekly and during the referral process, the staff needed to ensure the potential new residents were not considered wanderers. She stated additionally the Maintenance Director checked the doors and alarm system weekly. She stated they continued with the staff trainings on elopement prevention and response and monthly elopement drills. She stated they included the elopement trainings for all new hires during orientation and had Quality Assurance meetings to discuss the effectiveness and monitoring of their plan to prevent elopements. She stated if a resident eloped they could get dehydrated and require hospitalization, which could lead up to death. She stated it was the responsibility of all staff to ensure the residents did not elope but ultimately she was responsible for ensuring all staff followed their elopement policy. She stated approximately 95% of the staff had been re-trained on their new process to prevent residents from eloping. Record review of the facility's Missing Resident Action Plan dated 06/01/23 revealed, Action Taken: Head to Toe Assessment completed with no abnormal findings on 06/01/23 by charge nurse, Resident will continue with 1:1 monitoring for safety until transferred to secured unit at sister facility. Elopement risks assessments were completed for all residents in the building by the DON, ADON and Treatment Nurse. Elopement Risk Assessments will be reviewed and monitored weekly by the DON or designee. All exit doors were checked by the compliance nurse and Administrator for proper alarm functioning. No issues identified, completed 06/01/23,.Elopement drills were initiated by the Admin/DON/Designee for each shift including weekends, started 06/01/23. In-services: An in-service regarding resident elopement facility protocols were initiated 06/01/23 by the DON for all facility staff. The DON initiated an in-service on 06/01/23 for all staff that any resident that attempted to elope from the facility must be placed on 1:1 supervision immediately until transferred to secure unit. The Administrator and Director of Nursing will be notified immediately, start date 06/01/23 ongoing. In-services: All Nurses in-serviced by the DON that all residents must have an elopement risk assessment completed upon admission, quarterly, and as needed for changes in condition. All nurses not present will be in-serviced prior to performing work duties start date 06/01/23. Monitoring: The Administrator and DON will monitor for compliance and ensure all staff have been in-serviced on 06/01/23 and ongoing. Moving forward the Maintenance Director/designee would check all exit doors daily, start date 06/01/23 and ongoing. The Administrator would review the monitoring tool weekly for compliance, start date 06/01//23. Record review of the facility's Elopement Prevention and Response In-service Trainings from 06/01/23 to 06/03/23 reflected all staff from all shifts were trained, which included CNA's, LVN's , admissions, Dietary, therapists, housekeepers, clerical, receptionist, Medication Aides, Activities Director and other staff were trained on identifying the cause of wandering, intervention strategies and environmental modification. Record review of the facility's Elopement Posttests from 06/05/23 to 06/06/23 reflected all staff from all shifts were trained on what to do if the door alarms sounded off, if a resident eloped, resident exit seeking should redirect and report to nurse immediately, resident leaves without signing out was considered an elopement. Record review of all the facility residents Elopement Risk Assessments from 06/01/23 to 06/06/23 reflected, 53 Resident Elopement assessments were completed. Record review of the facility's Timesheet printed on 08/17/23 revealed they had one RN, and four CNA's working the night shift on 05/31/23 and they clocked out between 6:00 am and 7:00 am on 06/01/23. Record review of the Fire and Security invoice dated 06/02/23by an alarm company, After investigating I found that the buzzer at the doors would go off after the door went into its 15 second egress allowing the doors to be unlocked without anyone knowing. So, I re-wired the timer at every door so that when the door goes into egress the sounder will not go off until someone comes to the door and resets the keypad. Record review of the Fire and security's invoice dated 06/05/23 by the alarm company revealed, Customer wanted front door to lock as soon door is closed behind people entering building. Set keypad time to shorter open period. Door now locks when closed behind standard entry. Observations on 08/17/23 between 4:30 pm to 4:50 pm, with the Maintenance Director, The front entrance door and six exit hall doors (100, 200, 300, 400, 500 and 600) and one dining room door appeared to be in good working condition. They locked appropriately, and the alarms sounded off loudly and immediately after the panic bar was pressed to open the doors and it continued to sound off until the Maintenance Director pressed the code on the keypad to stop it. The front entrance door had a sign on it that read, Please Close Door Behind You. Observations from 08/16/23 and 08/17/23 did not reveal any residents who were exit seeking out of the facility. Record review of the facility's Elopement Prevention policy dated January 2023 revealed, Policy statement: Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopements. 1. The elopement risk assessment will be completed upon admission .identify the cause of wandering .Intervention strategies .Environmental modification .staff training . Record review of the facility's Elopement Response policy dated January 2023 revealed, Policy Statement: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented .Policy and interpretation and implementation: It is the responsibility of all personnel to report any resident attempting to leave the premises determine missing resident .should an employee observe a resident leaving the premises .should an employee discover the resident missing from the facility (Code orange), Deployment procedures .If unable to locate resident in the building .post return resident evaluation and care and documentation . Record review of the facility's Incident/Accident policy was requested from the Administrator and Interim DON on 08/16/23 at 10:05 am and on 08/18/23 at 09:01 am, and the administrator said they did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate treatment and services to prevent complications for one (Residents #30) of two residents reviewed for tube feedings. Observed at the bedside of Resident #30 was a de-clogger tool, it appeared to have residue on it. The de-cloggers were available in three locations on the medication cart, central supply room and treatment room; the de-cloggers were ordered to be restocked in January 2023. The facility failed to ensure the nurses were not using a de-clogger to unclog Resident #30's g-tube (Gastrostomy tube, tube inserted through the belly that brings nutrition directly to the stomach) without physician orders, without notifying the physician and without training. The Medical Director was not aware the nurses used a de-clogging device if there was an issue with a clogged g-tube. The use of the de-clogging device could cause serious harm to the resident, which could hospitalization. The nurse could have perforated the lining of the stomach or the intestine, and/or possible die from the use of the device. This failure placed residents at risk for perforation of the g-tube and/or intestinal wall, replacement of the g-tube, hospitalization, or even death. Findings included: An Immediate Jeopardy was identified on 02/21/23 at 08:11PM. The IJ template was provided to the facility on [DATE] at 08:11 PM. While the Immediate Jeopardy was removed on 02/23/22 at 05:35PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need of continuation of in-servicing and monitoring the plan of removal. Review of Residents #30's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Cognitive section of the MDS indicated Resident #30 severely impaired. The MDS reflected his functional status was dependent with ADLs and nutrition was via g-tube. The resident's diagnoses include cerebral vascular accident (stroke), gastroesophageal reflux disease (acid reflux), hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Review of Resident #30's comprehensive care plan dated 12/09/2021 revealed the resident will be free of side effects or complications related to tube feeding, insertion site will be free of signs and symptoms of infection, will maintain adequate nutritional and hydration status, and resident will be free from aspiration (inhaling foreign substance into airway or lungs). The care plan reflected no goals or approaches related to appropriate protocol for de-clogging the g-tube or the use of a g-tube de-clogger. Review of Resident #30's order summary report dated 01/16/2023 reflected, enteral feeding order, flush tube with 30 ml water before and after medication and feedings. Flush with at least 5 ml's of water between each medication. Review of Resident #30s order summary report dated 01/16/2023 reflected an enteral feeding order, Isosource 1.5 55ml/hr for 1800 ml total volume, 2250Kcals/day. Feeding may be disconnected/stopped for repositioning, bathing, incontinent care, appointments, or per family/resident. (There was no order to use a de-clogging tool if the feeding tube was clogged.) Review of Resident #30's Nurses progress note dated 10/14/22 the resident was sent to Emergency Department for a split in the g-tube tubing. The resident returned on 10/15/2022 post g-tube replacement. Observation and interview on02/21/23 at 02:44 PM revealed Resident #30 lying in bed with pillows around him for positioning; he had contractures (limited range of motion due to immobility) of lower extremities. The resident did not respond when greeted. The resident's eyes were open, but he did not respond when his name was called and when he was asked what his name was. The resident was positioned in bed on a low air loss mattress, tube feed formula Isosource 1.5kcal was infusing at 55ml/hr. A suction at bedside, de-clogging tool (labeled Enteral Feeding Tube Clog Remover) at bedside, on shelf with other tube feeding supplies such as an extra syringe, extra formula, and personal care items. Record review on 02/21/23 at 03:30 reflected no order for de-clogger tool in Resident #30s physician order summary. Record review on 02/21/23 at 03:35 reflected Resident #30 did not have a care plan that included the use of the de-clogger tool. Observation on 02/21/23 at 04:30 PM revealed the de-clogging tool remained at bedside in Resident # 30's room. Interview and observation on 02/21/23 at 04:31PM with LVN C revealed she has worked at the facility for 1 year in March 2022. The nurse showed the surveyor the supplies in room Resident #30's room which included: a pump, tubing, feeding, and a syringe which was dated and timed. There was also a de-clogger tool that was approximately 2.5 ft in length. The package was open, and it remained in the same place as noted at 02:44 PM. LVNC was asked what the de-clogger tool was used for. She stated she was not sure and had not seen the tool before. She proceeded to read out loud the wording on the package which reflected Enteral Feeding Tube Clog Remover. LVN C stated she had not and would not know where to find a new one if it were needed. LVNC was asked if she has ever used the de-clogger tool and she stated she had not and would not know how to use it. LVN C was asked if tool appears to have been used and she confirmed that it appeared to have tan colored residue on it covering the entire tip and that since it appeared used, she will throw it away. Nurse removed de-clogger from the room. Record review on 2/21/23 at approximately 04:45 PM of undated manufacture directions on package reflected the following: 1. Determine the length of the feeding tube and choose the wand that corresponds with the size. Caution: confirm that the tube has not been modified 2. Stop feeding prior to use. Remove any accessories that are connected to the tube. Clamp off the feeding set and disconnect from feeding tube. 3. Insert the wand into the feeding tube until you've reached the blockage. Rotate the wand clockwise and counterclockwise to break up the clog. 4. Once the clog is clear, flush the feeding tube with at least 30cc of warm water. 5. Dispose of the wand. 6. Reconnect the feeding set to the feeding tube and resume feeding. After record review of physician's orders for Resident #30 there was no evidence of an order to use on g-tube residents. Interview on 02/21/23 at 04:50 PM with RN I revealed she is an agency nurse and today was her first day at the facility. RN I was asked what she would do if the tube was clogged, and she stated there was a de-clogger at the bedside that could be used. She stated she had not had any need for it but if she did, she knew that one was available at the beside of Resident #30's room. RN I stated she was not a facility staff member, so she was not sure what the facility policy was regarding the use of the de-clogger but the de-cloggers are available, so she thinks they are ok to use if a resident's g-tube becomes clogged. RN I stated the de-clogger could be found in the central supply room that had the treatment supplies on 300 hall or she would ask someone since she was new. When asked if she had training to use this tool and was there an order for the tool to be used she replied that she was agency and today (02/21/23) was her first day. Interview on 02/21/23 at 05:15 PM with LVN H revealed she has worked at the facility for 13 months. LVN H was asked if she passed medications for g-tube or PEG tube residents and she stated, Yes I have 8 residents who get medications this way. She stated if a g-tube/PEG tube was clogged she would use her fingers and a tongue blade (medical grade flat wooden stick) to milk the tubing to unclog the tubing. She stated that it usually works well and has no other issues. LVN H was asked what happens if it does not unclog the tubing and she stated she would ask for someone else to help unclog the tube. She was asked if someone was not available what would she do and she stated: the facility has these things (cannot recall the name) that are available, but I try not use them. I would try water and milking the tube first. When asked what thing she was referring to that facility has, she was observed to look in her medication cart and produced a tool in packaging that reflected Enteral Feeding Tube Clog Remover. She stated she had not used it but was trained on it 13 months prior by a nurse who no longer was employed by the facility. Interview on 02/21/23 at 05:54 PM with LVN H revealed none of her residents need the de-clogger tool but there was a resident on another hall (Resident #30) who had frequent issues with the tube clogging, and she was aware of him having one most of the time at his bedside. LVN H was asked if there was any order in the chart for the use of the de-clogger on any of her residents and she stated no, but there probably should be. She stated she would not use it without an order and would not use it at all because she was not comfortable using the de-clogger tool. She stated she used the de-clogger when she first started 13 months ago (cannot recall what resident) when she was trained by a peer. LVN H stated the training she received was when the orientating nurse showed her how to use the device. LVN H stated there was no classroom training provided. She stated she did not sign skills check off to use the de-clogger device. She stated de-clogger tools were on the medication carts, in the central supply room which was locked up in the back. LVN H was asked how many times the tool may be used, and she stated it should be used only for 24 hours and night shift throws them away. She also stated she had not been trained by the DON or ADON on how to use the tool or how long it could be used. During an interview and observation on 02/21/23 at 05:59 PM LVN C stated there would have to be an order for the staff to use the de-clogger and it would be found on the nurse's TAR so that the medication aides do not have access to the order. She stated she thought the de-clogger may be in the supply room but had never used one at this facility. LVN C had not come across a time she needed to find this tool. She stated she had never used a de-clogger. LVN C was asked if she had received any training on how to use the de-clogger tool and she replied no. LVN C opened the drawers of her medication cart and no de-clogger tools were found on the cart. LVN C was asked if she knew how long the de-clogger was good for and she stated she does not know and would throw it away if it looked used or night shift would throw them away during their shift. Interview and record review on 02/22/23 at 05:08 PM LVN C was asked if she recalled writing a note on 10/14/2022 that reflected: Resident [#30's] g-tube leaking, assessed g-tube noted a split on mid (middle) part of tubing. Informed DON informed to transfer resident to hospital, medical director called, sister called to inform of transfer to hospital. She stated she remembered the note and was not notified of any issues with the g-tube from previous shift. She stated she recognized issue upon rounds and immediately stopped the feeding so it would not cause any further issues and notified the DON and doctor. She stated she started the process of transferring him to the hospital after receiving the order. LVN C was asked if she knows how the g-tube became split and, she stated she was not sure and could not figure out how it occurred, but it caused her concern enough to notify her DON and the doctor. LVN C stated that when she wrote the note on 10/14/22, she had not received any training for de-cloggers. LVN C was asked if she had received any in-service regarding the de-cloggers and, she stated yes today (02/22/23), she knows not to use them and was given a competency and a short test after she was given the education by the DON; after the issue was brought to the facilities attention. LVN C was asked what she would do if g-tube becomes clogged and, she stated she would notify the DON and doctor right away. Interview on 02/22/23 at 06:13 PM the admission Coordinator stated she has worked as the admissions coordinator for 2 months and was previously in medical records and central supply (which is one person for two roles) for about 2-3 months before that. She stated she also has her CNA certificate. She was asked what months she worked in central supply she stated in July 2022. She was asked if she had ever ordered any de-cloggers and she states she had not ordered any de-clogger tools while in the central supply/medical records position. The admissions Coordinator was asked if she ever saw them within the facility and she stated she saw them in the stock room in November 2022, there was about 5 individual devices within the treatment room. The Admissions Coordinator was asked if she had ever been asked to order them from the previous, or current DON or Administrator. She stated no and she didn't see any in central supply during her time in the position. The Admissions Coordinator was asked if she was aware of the risk of ordering them and she stated she was not familiar with what they are used for, so she was not sure the risks. The admission Coordinator was asked if she has seen them being used on any residents she states she has never seen anyone use them on residents. Interview on 02/22/23 at 04:57 PM with Central Supply and Medical Record (which is one person with two job titles) started working at the facility in September 2021 but was in a different role until he took on central supply and medical records in September 2022. Central Supply/Medical Record was asked if he had been told not to order the de-cloggers. He stated he has never been told not to order them until yesterday (02/21/23). Central Supply/Medical Records was asked who asked him to put in a new order and, he stated the previous DON asked him to order them in January 2023 because they were running low on the supply that was already in the facility. Central Supply/Medical Records was asked if nurses had access to the de-cloggers and, he stated the nurses had access to them because they were kept in the treatment room and there were some in the central supply room. Central Supply/Medical Records was asked if he knew if the previous central supply employee ordered them before. He stated he was not sure and that all he is aware of is that they were present when he took over the job. He stated he did a search on the ordering system that covered his time within the position which was between September 2022 to February 2023 and the order was placed was on 1/4/2023. Central Supply/Medical Records was asked when the first time was, he saw the de-clogger and he stated the de-cloggers were already present when he started the position.(September 2022) Central Supply/Medical Records was asked if he knew where else they were present and he stated they were available on the nurses carts and they had a main supply in his office and in the treatment room. Record review of supply order receipt reflected that on 1/11/2023 at 12:57 PM a delivery was received that included 1 box of clog remover: yellow 16F FRX 39.5cm, SKU # ENT912. Record review of Medline.com revealed 10 de-cloggers were in each box. https://www.medline.com/sku/item/MDPENT912 A telephone interview was conducted on 02/21/23 at 06:10 PM with the Medical Director, who was also Resident #30's attending physician. The Medical Director was asked if he is aware facility staff was using a de-clogger tool to unclog g-tube/PEG tube. He stated he was not aware of what the tool was. Once explained to him what the tool looks like and how the facility was utilizing it, he stated he was not comfortable with it being used on his residents. When asked what harm could come, he stated it could cause harm to residents, which could damage stomach lining, perforate the bowels and lead to hospitalization or worse. An Interview on 02/21/23 at 06:25 PM with the DON, revealed she started working at the facility in October 2022, approximately 5 months. The DON was asked how nurses were trained when they were newly hired. The DON stated the nurses were trained from peer to peer, so they get placed on the floor with another nurse for orientation. She stated they also attend a SNF clinic where they get competencies checked off in accordance with the facility policies and procedures. The DON was asked who specifically checks off the competencies for g-tube feeding and management, and she stated that herself (DON) and or the ADON can check off on training with the new staff nurses. The DON was asked if there was any orders for the use of the de-clogger tools and she stated there was a list of standing orders which come from the Medical Director, and the order for use of the de-clogger was included on the list. She stated the de-clogger tool was used to unclog a g-tube when they cannot be cleared with any other way. The DON was asked if part of the nursing competencies included how to use the de-clogger. She stated they can use the de-clogger after the peer-to-peer training. The DON was asked if the care plan included the de-clogger as an intervention. She stated it should be in the resident's care plan if it is needed. She stated the Medical Director gives standing orders to the facility for newly admitted residents and they are transferred from the form to the electronic medical record and was only done on a case-by-case scenario specifically for g-tube residents. The DON was asked if she knew of any residents who currently needed the de-clogger and she stated she was aware of Resident #30 having increased issues with clogging of his tube and he needed the de-clogger tool. She could not recall how many times it had been used on Resident #30 or which nurses used it. The DON stated if the de-clogger tool was needed, it was available in the supply room. The DON was asked if she knew the risk of using the de-clogger tool without proper training, or without a doctor's order, and she stated yes, it could cause perforation of the abdomen. An interview on 02/21/23 at 6:50PM with the DON revealed there was no standing order for use of the de-clogging tool. She provided a copy of the standing orders titled Standing orders for Nursing Home Patient. The orders related to g-tube care and management reflected Patients with peg: head of bed should be at _ [greater than] 30 degrees, hold tube feedings during repositioning. Give water bolus 200 cc _ [per shift] unless ordered otherwise. (600 cc per 24 _ [hours]). Record review of the facility's nursing policy and procedure manual 2003 Gastrostomy Tube Care revealed it did not include a procedure for the use of the de-clogger. The policy did not reveal the procedure for care of a g-tube that becomes clogged. Record review of in-service trainings on 02/21/23 at 07:00 PM reflected the following in-service topics in-service training topic: De-clogger- do not use; g-tube policy, de-clogger- do not use, staff notifying management if g-tube is clogged or unable to flush following physician orders. Record review on 02/21/23 at 07:05 PM of enteral medication administration skills competency revealed the following statement do not force any medication or fluid into the tube. Allow gravity to work. If necessary, gentle pressure may be applied after repositioning the resident. There was no use of the de-clogger tool on the competency skills check off. Record review of Nursing 2023 The Peer-Reviewed Journal of Clinical Excellence titled Best Practices for unclogging feeding Tubes in Adults revealed: Follow your facility policy and procedure for unclogging [NAME] [enteral access device]. The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends warm water as the best initial choice for trying to unclog a feeding tube. First, attach a 30- or 60-mL piston syringe to the feeding tube and pull back the plunger to help dislodge the clog. Next, fill the flush syringe with warm water, reattach it to the tube, and attempt a flush. If you continue to meet resistance, gently move the syringe plunger back and forth to help loosen the clog. You can then clamp the tube to allow the warm water to penetrate the clog for up to 20 minutes. If water fails to unclog the tube, ASPEN guidelines recommend using an activated pancreatic enzyme solution.1-4 However, use of a pancreatic enzyme solution requires a healthcare provider's prescription and should be attempted only by nurses familiar with the procedure according to facility policy and procedure.3 Additional second-line interventions include using a commercially available enzyme de-clogging kit or mechanical de-clogging device. These also must be used in accordance with facility policy and procedure and only by experienced clinicians. If the tube can't be unclogged by these methods, ASPEN recommends replacing it. [NAME], [NAME] BS, RN; [NAME], [NAME] MSN, RN, CRNP. Best practices for unclogging feeding tubes in adults. Nursing 48(6):p 66, June 2018. | DOI: 10.1097/01.NURSE.0000532744.80506.5e https://journals.lww.com/nursing/Fulltext/2018/06000/Best_practices_for_unclogging_feeding_tubes_in.16.aspx#:~:text=First%2C%20attach%20a%2030%2D%20or,to%20help%20loosen%20the%20clog. On 02/21/23 at 8:11 PM the Administrator, DON, Regional RN, Area Director of Operation was informed of the Immediate Jeopardy (IJ) and the facility was informed the POR requested. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 02/23/23 at PM and reflected the following: .The facility failed to ensure that nurses were not using a de-clogger to unclog resident g-tubes without physician orders, without notifying the physician and without training. Interventions: On 2/21/2023 Resident #30 was immediately assessed in the facility by the DON, Medical Director notified. Medical Director resident sent to ER for evaluation of stomach and g-tube site due to estimated wait time length of duration for Kidney, Ureter, Bladder abdominal XRAY by diagnostic imaging company. Results were negative, no issues found. (Completed assessment after immediate in-service/competency check by Regional Nurse) On 2/21/2023 G-tube residents were assessed via SBAR assessment, by DON, ADON, and Regional Nurse Consultant, for change of condition with the g-tube site or signs/symptoms of an infection, MD notified, new orders for KUB for the 7 residents with g-tubes. Residents will continue to be monitored by DON, ADON every shift until results of KUB are obtained. (Completed assessments after immediate in-service/competency check by Regional Nurse) Residents with G-Tubes: Resident #47, #51, #55, #58, #45, #42, #63 and #30 On 2/22/2023, 1:30pm Kidney, Ureter, and Bladder abdominal X-ray to be completed by diagnostic imaging company for 7 g-tube residents. Results for all 7 residents were negative for stomach perforation as of 2/22/2023 at 5:00pm. Residents with G-Tubes: Resident #47, #51, #55, #58, #45, #42, #63 On 2/21/2023 G-tube de-clogger was immediately removed from the resident room, Resident#30 On 2/21/2023 DON, ADON, and Regional Nurse Consultant searched g-tube resident rooms to ensure the absence of de-cloggers in the resident room and medication carts within the facility. During facility audit, there were zero de-cloggers found in resident rooms. One de-cloggers was located on nursing cart on 500 hall, immediately removed. An unopened box was located in the central supply office, immediately removed. No other de-cloggers found in facility audit. Upon reviewing the order history from medline the last time facility ordered the de-cloggers was on 1/12/2023 and was a quantity of 1 box. On 2/22/2023, Administrator contacted medline supplier and has since had the item removed from the facility formulary list which prevents facility from ordering de-cloggers in the future. Residents with G-Tubes: Resident #47, #51, #55, #58, #45, #42, #63 and #30 On 2/21/2023 The Regional Nurse Consultant 1:1 in-serviced the DON and ADON on the g-tube policy, and that no de-cloggers were to be used in the facility. On 2/21/2023 The Regional Nurse Consultant 1:1 in-serviced the DON and ADON on physician notification if g-tube is unable to be flushed. On 2/21/2023 DON, to immediately in-service during 2/10 shift on 2/21/23, then prior to the start of their shift the 10/6 shift coming in on 2/21/2023, ADON to in-service 6/2 shift prior to the start of their shift on 2/22/2023. On 2/21/2023 Regional Nurse Consultant, placed visual Alert regarding G-tube clogged? CALL THE DOCTOR immediately placed in each g-tube resident room, nurses' cart, and 24-hour report book. Residents with G-Tubes: Resident #47, #51, #55, #58, #45, #42, #63 and #30 Immediately starting 2/21/2023, The DON or ADON will complete g-tube competency with each staff nurse, completed 2/22/23. Immediately starting 2/21/2023 DON or ADON will complete g-tube competency with agency nurses or new nurse hires prior to start of their first shift. Immediately starting 2/21/2023, The DON or ADON will in-service oncoming staff and agency nurses prior to the start of their shift, to ensure that de-cloggers are not to be used in the facility. Immediately starting 2/21/2023, The DON or ADON will check competencies for G-tubes, for oncoming nurses and agency nurses, prior to the start of their shift, to ensure that de-cloggers are not to be used in the facility. *****The following in-services were initiated immediately by the DON, ADON and Regional Nurse Consultant on 02/21/2023: To be completed by Noon on 2/22/2023, Any licensed nurse does not present or in-serviced on 2/21/2023, will not be allowed to assume their duties until in-serviced. New Hire nurses or agency nurses will be in-serviced prior to start of shift by DON, ADON. o Nurse Staff will be Inservice on the following: Inservice staff on G-tube policy Inservice staff on following physician orders Inservice staff notifying physician if g-tube is unable to be flushed or clogged Inservice staff notifying DON/ADON/Nursing Supervisor if g-tube is unable to be flushed or clogged or other concerns related to the g-tube To be completed on 2/22/23, G-tube Protocol Test administered to all licensed nurse staff once g-tube competency check, education, and in-servicing are complete, to ensure understanding of the facility protocols related to g-tubes. The medical director was notified of the immediate jeopardy situation on 02/21/2023 at 8:30pm Policy reviewed with medical director, and he agreed with plan. Monitoring: Immediate monitoring started on 02/21/2023. DON, ADON, Treatment Nurse will monitor all rooms for residents with G-tubes every shift x 7 days per week to ensure de-cloggers are not present or in use. Immediate monitoring started on 02/21/2023. DON, ADON, Treatment Nurse will interview 2 nurses daily x 7 days per week. Charge nurses will be asked what to do if g-tube is clogged or unable to be flushed. In-servicing will be provided as needed. Immediate monitoring on 02/21/2023. DON, ADON, Treatment Nurse will interview 2 nurses daily x 7 days per week. Charge nurses will be asked if they have used or seen a de-clogger in use for residents with g-tubes. If present, the de-clogger will be removed from the facility. In-servicing will be provided. MD will be notified for additional orders to treat. Immediately on 2/22/23, the G-tube Protocol Test was administered to each licensed nursing staff once the G-tube competency check was completed to ensure understanding of the facility protocol. Administrator will review all monitoring tools 5 days per week. All findings will be reported monthly during the QAPI meeting x 3 months Monitoring of the facility's Plan of Removal to confirm the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) included the following: Observation on 02/21/23 at 09:00 PM revealed Resident # 30's room had no de-clogger tool at bedside. Observation on 02/21/23 at 09:05 PM revealed no de-clogger tools were on LVN H's medication cart. Observation and Interview on 02/21/23 at 09:12 PM DON accompanied to storage room named Clean Utility Room where tube feeding supplies were stored. Storage room no evidence of de-clogger tools. DON stated they did an immediate sweep of the building as part of the POR. Observation and Interview on 02/21/23 at 09:17 PM revealed no de-clogger tools on LVN C medication cart. Observation on 02/22/23 at 11:15 AM of Resident #30, TF was disconnected and paused. A sign was at the head of bead that reflected if clogged call MD! Do not use with a picture of de-clogger tool. Observation and record review on 02/23/23 at 09:40 AM revealed residents #55, #58, #47, #42, #63, #45, #51 and #30 with g-tubes/ tube feedings, there was signs observed at the heads of beds that reflected G-tube clogged? Call the doctor do not use these with a picture of the de-clogging tool. The signs were posted in the above listed resident rooms. Record review of KUB (kidney ureter bladder x-ray of abdomen) results on 02/23/23 at 12:45 PM was conducted for the following residents: Resident #55, Resident #47, Resident # 42, Resident #63, Resident #45, Resident #58, Resident # 51. Results did not indicate any injury. Exam was conducted per the POR. Interview on 02/22/23 at 10:26 AM with LVN K stated she worked the 6 AM to 2 PM shift and has worked here since November 2022. LVN K was asked if she had any medications she passed to residents with a g-tube and she stated yes, she passed medication through g-tube or PEG tube. LVN K was asked if the tube became clogged what she would do and she stated she would use warm water to try and flush the tubing and milk the tubing to see if she can free the clog. She stated if that did not work, they send resident out to the ER to be checked there. She stated she had not received any training on how to use the de-clogger tool. LVN K was asked how the training process was for her upon hire and she stated it was swift because they did not have a lot of staff. She stated she spent 3 days on the floor orientating with another nurse and she also attended a SNF clinic training that was one day of classroom. She stated the training included competencies and nursing skills check off. LVN K was asked what hands-on training was provided and she stated hands on training was done depending on what the topic was. She stated the ADON does most training and if the topic can only be taught by an RN, the DON does, the training. LVN K stated documentation training is provided by the MDS nurse E and skin treatments is taught by the treatment nurse LVN. LVN K was asked specifically who did skills check off for her including g-tube management and maintenance and she stated usually the ADON does the skills check off but for her the DON did her check off. She stated she did not receive hands on training for the use of the de-clogger tool. LVN K was asked if she received any education on what to do if the g-tube were to become clogged and she stated she will call the doctor. LVN K was asked if she[TRUNCATED]