Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 5 residents (CR# 1) reviewed for quality of care. The facility failed to immediately contact emergency services and transfer CR #1 to the hospital when she complained of pain to the head, and was on a prescribed anticoagulant medication, after an unwitnessed fall on 11/21/2023 at 9:25 pm. CR#1 was life flighted to the hospital after vomiting three times after the fall. An IJ was identified on 11/30/2023. The IJ template was provided to the facility on [DATE] at 1:59pm. While the IJ was removed on 12/1/2023 at 3:40pm, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. The failure placed residents who are at risk for falls and on anti-coagulant medication at risk of delayed treatment that could lead to decline in health and death. Findings Included Record review of CR #1's face sheet dated 7/3/2023, revealed an [AGE] year-old female who was admitted to the NF on 07/03/2023. Her diagnoses included the following: chronic respiratory failure with hypoxia (occurs when the respiratory system cannot adequately remove carbon dioxide), chronic obstructive pulmonary disease (a group of lung disease that makes it difficult to breathe), urinary tract infection ( infection of the urinary system), acute embolism and thrombosis of deep vein of left lower extremities (blockage of the artery), hypertension (high blood pressure), severe protein calorie malnutrition (lack of protein and calories to meet nutritional need), atrial fibrillation (rapid heartbeat that causes poor blood flow), hypotension (low blood pressure), peripheral vascular disease (poor circulation of blood flow to the limbs), congestive heart failure (a chronic condition that prevent the heart from pumping blood as well as it should) depression (a medical illness that effect the mood), and chronic kidney disease (the inability of the kidney to filter waste and excess fluid from the blood). Record review of CR#1's quarterly MDS dated [DATE] BIMS summary score coded her as 07 indicating she was moderately impaired for cognition for decision making. She was coded as having no behaviors. Record review of CR#1's physician's order revealed an order for Apixaban (oral blood thinner used to prevent blood clotting and stroke) oral 5 mg two times a day. Record review of November 2023 MAR revealed documentation that Hydrocodone -Acetaminophen tablet5-325 was given at 8:00 pm, Apixaban 5mg was given at 5:00pm on 11/21/2023. Record review of the Nurse's investigation report dated 11/21/2023 revealed at 9:40 p.m. CR#1 was observed lying on the floor on her left side next to her bed with a blanket. The resident stated that she fell when she was going to the bathroom. She was noted with a small bruise to the lateral aspect of right hand, a small abrasion to her lower back and no bleeding noted. Complain of head pain no bruising, redness or swelling noted. Two staff members assisted the resident back to bed and she was cleaned up. The resident was assessed for injuries, neuro checks were initiated, and pain medications were given. Blood pressure readings for CR #1 were not identified as a concern. ?9:40PM: 159/84 ?10:10PM: 144/80 ?10:40PM: 102/87 Record review of nurses for CR#1 dated 11/21/2023 at 11:40 p.m. reflected in part, family came to visited patient at 10:40 pm after she was notified that patient had a fall and family requested that an x ray be done and resident to be sent to the hospital. EMS was called and arrived. Patient had 3 emesis from 10:40 pm till she left by EMS at 11:34pm. Emesis was greenish yellow and moderate amount. Patient, awake and alert during this time. While EMS was in room doing assessment, patient right side of face become droop and she could not talk back. They stated that patient will go life flight to hospital downtown. EMS left at 11:34 pm. Guardian and family in room and aware of situation. Record review of EMS records revealed EMS was called at 11:17 p.m. by RN H. In an interview on 11/28/2023 at 11:46 a.m. CNA F she said she was doing her rounds on 11/21/2023 and around 9:30 p.m. she went to CR#1's room and she found the resident on the floor. She said she asked CR#1 what happened, and she told her she was going to the restroom and fell. She said she did not move her, but quickly went to get the nurse. She said RN G went to the room assessed the resident and on completion of the assessment RN G asked CR#1 some questions, took her vitals, and she assisted RN G with putting the resident back to bed. CNA F said CR#1 then pointed at her head in a gesture to indicate that her head was hurting. CNA F said the nurse then brought CR#1 a clear cup with a pill, believed to be Tylenol and gave it to the resident. In an interview with on 11/28/2023 at 2:30p.m. RN G said she was called by CNA F to come CR#1's room because the resident was on the floor. She said she went to the resident's room, and she was lying on her left side on the floor next to her bed. She said she assessed the resident and did not see any redness or swelling. She said there was a small bruise to the hand and an abrasion to the lower back with no bleeding. She said after her assessment CNA F assisted her in putting the resident back to bed. She said the resident pointed to her head and said in Spanish that her head hurt. She said she called the family and NP. She said the NP told her to monitor the resident and give her pain medication and she said she gave her Tylenol. She said she did not remember if she asked the resident if she hit her head when she fell. Further interview with RN G revealed she followed the fall protocol by assessing the resident, calling the NP and doing neuro checks. In an interview with the DON on 11/28/2023 at 3:58 p.m. regarding CR#1's fall, she said RN G assessed CR#1, called the doctor, the family and did neuro checks. She said RN G followed the physician's order to only monitor resident and not sending the resident to the hospital. She admitted that she did not see any orders for Tylenol to be given and no documentation that Tylenol was given. In an interview with RN H on 11/28/2023 at 4:43 p.m. she said she was working the night shift and was on Station 2 taking report at the start of the shift. She said she did not assess CR#1 because when she got to Station 1; EMS was in CR#1's room assessing her. She said when she was talking to the family they told her CR#1 had vomited and they were requesting an x-ray to be done. She said the resident vomited twice when she was in the room and her face became droopy and then she became unresponsive, at that point EMS was in the room, and they decided to life flight her to the hospital because they thought she was having a stroke. She said CR#1 left for the hospital around 11:30 p.m. on 11/21/2022. In an interview with the NP on 11/29/2023 at 9:14 a.m. he said he was called on 11/21/2023 at 9:45 p.m. regarding CR#1's fall. He said he gave orders for the nurse to give the resident pain medication. At 11/21/2023 at 9:53pm he received a text from the facility stating the family of CR#1 wanted an x-ray to be done and he gave orders for x-ray and CT scan of the head to be done. He said he told the nurse she was to call the on-call nurse as he was not on call. I an interview with FM A on 11/29/2023 at 1:43pm she stated she arrived at the facility on 11/21/2023 at 10:30pm. She said she observed CR#1 lying in bed with a dry green (bio) type of vomit on her clothing. It appeared dry making her think no one had checked on the resident for a while. She stated FM#B arrived at 10:40pm. and told the 10-6 shift nurse that there was a bump on the side of CR#1's face and x rays were needed. She stated the nurse replied, Why? There's nothing wrong with her. FM A said they demanded that 911 should be called. FM A said RN H responded that they needed permission. FM A said 911 was eventually called and arrived sometime after 11:00pm. In an interview with FM B on 11/29/2023 at 1:50pm she stated she visited CR#1 on 11/21/2023 and left the facility at 8:10pm. She said at 10:10pm she received a called from the facility about her CR#1's fall. In an interview with RN H on 11/29/2023 at 2:55pm she said she knew CR#1 was on an anti-coagulant. She said she called the NP and told him about CR#1 complaining about her head hurting after her assessment and neuro checks. The NP told her to administer medications for pain. RN H said she administered Tylenol because CR#1 had already had her hydrocodone and it was too soon to administer another tablet; therefore, she gave her Tylenol. She said she did not ask the NP what pain medication she should give. She said she should have asked the NP for an order since there was no order for the Tylenol. Further interview with RN H regarding fall policies of a resident that had an unwitnessed fall and was currently taking ant-coagulants. She responded, I don't know. She said she would need to look at the policy to make sure she gave the correct answer. In an interview with the DON on 11/29/2023 at 3:23pm. she confirmed the fall policies for a resident with an unwitnessed fall and taking ant-coagulant medication was they should always be assessed (head to toe), and neuro checks conducted, then notify NP. If there was an emergency, they should send the resident out immediately. The DON stated RN H requested x-rays and CR#1 was sent to the hospital after the family's request. The DON stated the resident began to vomit prior to EMS being called. The DON stated there was no order for Tylenol but stated RN H received verbal authorization from the NP to administer Tylenol. The DON was then asked why it took the facility almost 2 hours to call EMS, and she responded, I don't know. Record review of the undated facility policy and procedure on Fall Management reflected in part, 2. the resident will be checked for any abnormalities i.e. a. deformed, discolored or painful body parts. B. Bumps, C. Bruises, D. Cuts, E. Abrasions, F. Scrapes, G. Confusion and H. Level of consciousness. PLAN OF REMOVAL CR #1 was transferred to the hospital on 11/ 21/ 23. The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting on 11/30/23 to review the IJ template and Plan of Removal. On 12/1/23 the Administrator and Director of Nursing completed a route cause analysis using the 5 whys and added to the ADHOC QAPI information. On 11/30/23 the Director of Nursing and Assistant Director of Nursing assessed residents who had an unwitnessed fall in the last 10 days for any signs or symptoms of headache, vomiting, or abnormal findings to the scalp/head with no adverse findings. The Director of Nursing initiated an in-service on 11/30/23 with licensed nurses. Topics included: Fall Procedures, specifically on activating the emergency response system (911) for any residents on anticoagulants who fall and present with signs or symptoms of head injury (acute headache, vomiting, or abnormal findings to the scalp/head). 911 should be activated upon identification of the abnormal findings. Licensed Nurses will be educated before starting their next shift. Education will be included in orientation. Education will be completed on 12/1/23. The Director of Nursing initiated an in-service on 11/30/23 with licensed nurses. Topics included: completing thorough assessments post-fall with considerations for residents on anticoagulants. Licensed Nurses will be educated before starting their next shift. Education will be included in orientation. Education will be completed on 12/1/23. The Director of Nursing initiated an in-service on 11/30/23 with the certified nursing assistants. Topics included: CNAs should report to their charge nurse any changes in condition from the resident's normal behavior including changes after a fall and emergencies. Certified nursing assistants will be educated before starting their next shift. Education will be included in orientation on Education will be completed 12/1/ 23. The Director of Nursing provided 1:1 education with RN H and RN G on (1 2/ 1/ 2023). Education included Fall procedures and activating the emergency response system (911) for any resident on anticoagulants who fall and present with signs or symptoms of head injury (acute headache, vomiting, or abnormal findings to the scalp/head); 911 should be activated upon identification of the abnormal findings; and completing thorough assessments post-fall with considerations for residents on anticoagulants. The Regional Nurse Consultant provided 1:1 education with the DON and ADON on (12/1/2023). Education included Fall procedures and activating the emergency response system (911) for any resident on anti-coagulants who fall and present with signs or symptoms of head injury (acute headache, vomiting, or abnormal findings to the scalp/head); 911 should be activated upon identification of the abnormal findings; and completing thorough assessments post-fall with considerations for residents on anticoagulants. The Administrator and DON reviewed the policy on Fall Management, Changes of Condition, and Residents on Anticoagulant medications with no changes required. Monitoring the POR on 12/1/2023: During the survey monitoring, the Administrator was interviewed regarding what she believed was the root cause of the IJ. Administrator believed a delay in sending CR#1 to the hospital, via, 911 was an unclear communication response between the registered nurse and nurse practitioner. There is a plan in place to monitor this issue, which the medical staff should meet at lease 2-3 per week and create a monitoring log to avoid this issue occurring again. The Administrator expects the Director of Nursing to monitor all the systems daily as it relates to the IJ tags, physician notification and ensuring thorough and immediate documentation in the system. During the survey monitoring, the Director of Nursing (DON) was also interviewed regarding what she believed was the root cause of the IJ. The DON believed CR#1 should have immediately been sent out of the facility, via, 911 because she was taking anticoagulant, and the medical doctor should have been called instead of the nurse practitioner. The DON said the registered nurses notified the nurse practitioner because the medical director works at a clinic, which closes at 5pm so the next point of contact was the nurse practitioner as it was after 5pm. The DON plans to monitor this issue by following up daily on residents who are prescribed anticoagulants and to be proactive in ensuring clear instructions are given to the nursing staff by the doctor. The DON expectations of the RN's are to follow protocols when getting orders from the doctor. The RN must paraphrase back to the doctor what they understand so that the order is clear. The DON indicated she personally evaluated each resident, who are administered anticoagulants, for neurological deficiencies. Record review of the facility POR Binder revealed: revealed an Ad HOC QAPI meeting on 11/30/23 to review the IJ template and Plan of Removal. On 11/30/23 In-Service trainings initiated by the DON to licensed nurses on Fall Procedures, activating the emergency response system (911) for any residents on anticoagulants who fall and present with signs or symptoms of head injury (acute headache, vomiting, or abnormal findings to the scalp/head, and changes in condition. The Regional Nurse consultant completed a 1:1 education with DON and ADON on 12/1/2023 on Fall procedures, activating response system (911) should be activated upon identification of the abnormal findings; and completing abnormal findings; and completing thorough assessments post-fall with considerations for residents on anticoagulants. On 12/1/23 between 8:30am - 3:30pm, the POR monitoring was conducted. The following CNAs were interviewed CNA G, CNA H, CNA I, CNA J CNA K. CNA L, CNA M, CNA N and CNA O were asked what training they had received. Each CNA indicated they had received In-Service training on change of condition (identifying a change in the norm for the resident, like the resident isn't talking or responding, unable to wake up, and a resident who is experiencing depression).They also stated thy were also in-service on falls, immediate notification to the charge nurse and dialing 911 themselves if unable to locate a nurse in an emergency (life or death) situation. Each CNA stated they received their training at the beginning of their shift on 11/30/23 and on 12/1/23. Each stated they understood their responsibilities of Certified Nursing Assistant. The CNAs were able to demonstrate understanding of the in-service training received. On 12/1/23 between 8:30am - 3:30pm, the POR monitoring was conducted. The following RN's and LVN's were interviewed, RN I, RN J, LVN A, LVN B, LVN C, and LVN D. All were asked what training they had received. Each stated they had received In-Service training on change of condition, falls, immediate notification and dialing 911 and the importance in speaking with a MD or calling the on-call MD. Record review of the POR revealed in-service signatures of all medical personnel on fall, change of condition and initiating emergency response through 911. The Administrator was informed the Immediate Jeopardy was removed on 12/01/2023 at 3:40 AM. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.