**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident received care, consistent with professional stands of practice, to prevent pressure ulcers for 1 of 4 residents (Resident #95) reviewed for quality of care. 1. The facility failed to implement interventions to prevent Resident #95 from developing a stage 3 pressure injury to the sacral area. The facility did not assess Resident 95's skin to determine if she had pressure ulcers due to resdient refusal and did not identify a Stage III pressure ulcer to her sacrum which was identified when she was transferred to the hospital and was infected. Resident #95 was diagnosed with sepsis at the hospital. 2. The facility failed to accurately assess the skin of Resident #95. RN A did an incomplete skin assessment and documented Resident #95's skin was intact with no skin issues. 3. The facility failed to document Resident #95's refusal of skin assessments. An Immediate Jeopardy (IJ) situation was identified on [DATE] The IJ template was provided to the facility on [DATE] at 12:14 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopordy and a scope of Pattern due to the need for monitoring of corrective measures and the effectiveness of its corrective plan. These failures could place residents at risk of inaccurately assessing resident's condition, preventing pressure injuries, a decreased quality of life, hospitalization, and death. Findings included: Review of Resident #95's admission record, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of colon (cancer of large intestine), systemic lupus erythematosus (autoimmune disease), Parkinson's disease (a movement disorder of the nervous system) and neuralgia (nerve pain) and neuritis (nerve inflammation). Review of Resident #95's admission MDS, dated [DATE], revealed occasional urinary incontinence. Review of Resident #95's quarterly MDS dated , [DATE], revealed a BIMS score of 15, indicating intact cognition. Further review of the MDS revealed Resident #95 was at risk of developing pressure ulcers/injuries, had pressure reducing device for bed and turning/repositioning program and did not have pressure ulcers/injuries. The MDS section GG functional abilities revealed Resident #95 was independent with eating, toileting, transferring and required supervision with showering/bathing self. Review of Resident #95's care plan, dated [DATE] revealed Resident #95 was at risk for unavoidable pressure injury development or decline of skin integrity with a goal to maintain intact skin with no skin breaks. Interventions included: Clean and apply moisture barrier after each incontinent episodes . Educate resident/family/caregivers of causative factors and measures to prevent skin injury . Encourage/Assist with turning and repositioning . Pressure redistribution mattress . Weekly skin checks . Review of Resident #95's weekly skin assessment, dated [DATE], comleted by LVN X, revealed the following: no alteration in skin; skin color was normal, skin temperature was warm, skin moisture was normal, and turgor was fair. Review of Resident #95's weekly skin assessment, dated [DATE], completed by LVN y, revealed the following: no alteration in skin; skin color was normal, skin temperature was warm, skin moisture was normal, and turgor was good. Review of Resident #95's weekly skin assessment, dated [DATE], completed by RN A, revealed the following: no alteration in skin; skin color was normal, skin temperature was warm, skin moisture was normal, and turgor was good. Review of nurse note dated [DATE] at 08:50 AM, written by LVN P (Agency Nurse) revealed, nurse was notified by CNA that resident was needing extensive assistance to transfer to w/c. nurse came into patients room and noticed that she was lethargic. Ask resident if she was in any pain and she stated 'no'. Vitals were taking at this time 153/95 B/P, p103, t 98.6, r16, O2 93. Family was visiting in facility and wanted [Resident] to be sent out. Explained DON and Doctor would need to be notified and they would decide transfer. While monitoring O2 sat pulse was noted as elevated to 130 bpm. DON and Doctor was notified and the OK to send patient to hospital. [Family members] of resident was notified. They requested resident to be sent to [Hospital Name]. Resident was able to verbally respond to nurse. She was unable to dress herself and two watery stools were notated by staff. EMS was called and resident sent to hospital. Review of Resident #95's Nursing Home to Hospital Transfer From dated [DATE] completed by RN F, revealed reason for transfer: unresponsive. Review of Resident #95's hospital admission history and physical, dated [DATE] revealed mild discomfort in her buttocks. Review of Resident #95's hospital records dated [DATE] revealed problem list included Sepsis (a serious condition in which the body responds improperly to infection) due to methicillin resistant Staphylococcus aureus (MRSA - bacteria that has become resistant to many antibiotics) with acute renal (kidney) failure and tubular necrosis (damage to tiny tubule cells of the kidneys) without septic shock, lactic acidosis (buildup of lactic acid in bloodstream), diarrhea of presumed infectious origin, pressure injury (a sore that develops under pressure) of sacral region stage 3, and cellulitis (bacterial skin infection) and abscess (a painful, collection of pus) of buttock. Review of Resident #95's hospital admission History and Physical dated [DATE] revealed in part: The patient is a [AGE] year-old female who presents with diarrhea and acute renal failure with possible buttock cellulitis. She reports experiencing diarrhea but has not had any episodes today. She also reports no associated symptoms of fever or chills. There have been no instances of vomiting. Additionally, she mentions mild discomfort in her buttocks. Negative for fever, chills, or vomiting. Review of Resident #95's hospital CT abdomen and Pelvis WO contrast results, dated [DATE], revealed in part: Addendum #1 Also noted on the exam but not mentioned in the exam report is considerable asymmetric edema (swelling) involving the right labial area without soft tissue gas or drainable abscess. This is an asymmetric finding in the labial region. Very subtle fat-containing direct inguinal hernias (a bulge or lump that occurs in the groin region) also evident previously and currently but not significant. Also history included symptoms of right and left lower abdominal pain .Impression .7. New superficial subcutaneous mass like density in the posterior left inferior buttocks area which could represent fibrotic or active inflammatory sequelae of a left decubitus ulcer. No soft tissue gas or ulceration evident. 8. Diffuse reticular edema throughout the subcutaneous tissues of the posterior buttocks areas and in the presacral pelvic cavity areas could relate to a left inferior buttocks decubitus ulcer but no drainable fluid or abscess noted. Review of Hospital records wound care flow sheet revealed in part: Wound - Date First Assessed:[DATE] Time First Assessed:1515 Primary Wound Type: Other (comment) Properties Group inflamed and tender Side: Right Location Specific: buttocks Drainage amount: scant Drainage Characteristic: blood, bright Odor: Odor Current Dressing: none; open to air Dressing Applied: ABD pad; gauze fluffs (Kerlix Fluffs) Dressing Appearance: clean, dry and intact Wound Base: edematous; moist; pink; red Periwound Area: edematous; redness; moist; swelling Wound Edges: Open . Date First Assessed:[DATE] Time First Assessed:1517 Location Specific: labia Drainage amount: small Drainage Characteristic: purulent; tan; thick Odor: none Current Dressing: ABD pad; gauze fluffs (Kerlix Fluffs) Dressing Applied: ABD pad; gauze fluffs (Kerlix Fluffs) Dressing Appearance: clean, dry and intact Wound Base: edematous; red; ecchymotic; moist Periwound Area: ecchymotic; edematous; redness; swelling; moist Wound Edges: Open . Review of Resident #95's hospital records revealed, Consult notes dated [DATE] [AGE] year-old with staph sepsis now with tachycardia. admitted 3 days ago with abdominal pain and diarrhea. She is found to have cellulitis. Blood cultures positive for MRSA. She has had a sinus tachycardia since admission. She was being taken for debridement this afternoon and noted to have a heart rate of 200. Telemetry suggestive of SVT. No EKG performed. Surgery has been postponed. Heart rate improved. No chest pain or shortness of breath. Review of Resident #95's hospital Discharge summary dated [DATE] revealed in part: Discharge diagnosis: Bacterial pneumonia, unspecified Acute hypoxemic respiratory failure secondary to PNA and volume overload Septic shock secondary to PNA Perineal wound, POA SSTI secondary to MRSA, POA MRSA bacteremia secondary to perineal wound, SSTI, POA Acute exacerbation of diastolic CHF AKI Acute lactic acidosis . Briefly, this is a 79 y.o. year old female who presented with on [DATE] with a perineal wound. Blood cultures were positive for MRSA. She underwent I&D on [DATE] and [DATE]. Additionally, she underwent robotic colostomy placement on [DATE]. On [DATE], she was noted to be more hypoxemic requiring escalation to HFNC. CXR demonstrated worsening bilateral pleural effusions. TPCCC was consulted for acute hypoxemic respiratory failure. Her antibiotics were escalated but her hypoxemia continue to worsen. She was eventually placed on BPAP and transferred to the ICU because of hypotension. Vasopressors were initiated. She remained DNR and her clinical deterioration was discussed with the[family members] at bedside. They elected to transition to comfort care. Condition at the time of discharge: deceased . A phone interview on [DATE] PM at 12:26 PM with CNA D revealed Resident #95 did pretty much everything for herself and staff just brought her meals. CNA D stated Resident #95 would sometimes go to the dining room and walk or take herself in her w/c and was very independent. She said when Resident #95 was in the bathroom she would offer her help and Resident #95 would say no. CNA D stated she did not see Resident #95's skin because the resident would not allow it. An interview on [DATE] at 12:51 PM, RN F stated he only worked weekends downstairs on the rehab hall. RN F stated he admitted Resident #95 before she went upstairs for long term care. RN F stated on [DATE], the DON had asked him to go upstairs because the restorative aide had gone to do restorative with Resident #95, and she was lethargic and had a change of condition. RN F stated when he got upstairs, LVN P had called the doctor. RN F stated he did not see Resident #95 and helped with the transfer paperwork then went back to work downstairs. An attempted phone interview with LVN P (agency nurse) was unsuccessful on [DATE] at 12:58 PM. An interview on [DATE] at 1:01 PM, the DON stated facility nurses did their own wound treatments and went through training with herself or another nurse, and she had done in services on wound care, infection control and wound stages. The DON stated the risk to residents if wound care was not done was infection, they could become septic, and it would be harmful to the resident. She stated nurses were supposed to assess skin weekly and they were trained through Lippincott's which taught them wound care. The DON stated she also trains the nurses and would bring in the nurse during an assessment and explain what they were supposed to do, and when to notify the wound care doctor. She said nurses reported to her any skin changes because it was a change in condition, an incident report would be completed, and she would contact the wound Doctor and he then took over from there. The DON stated the CNA's were to report skin changes to their nurse. The DON stated she hired a wound care treatment nurse today because they had wounds and she felt like they could keep an eye on the skin, and the skin assessments would be consistent with one person doing them. She said everybody is going to document different and it would be consistent with a would care nurse. The DON stated Resident #95 was alert and oriented x 4 and did everything for herself. She said Resident #95 would shower herself and staff did set up and got towels. She said Resident #95 was modest and because of her culture would not staff look at her skin. The DON stated Resident #95's refusals were documented and should be in the EHR. She said the day the agency nurse worked the day Resident #95 was sent out did a paper progress note because she could not get logged into the EHR. The DON stated she was not at the facility when Resident #95 was sent out but LVN P had called her and she had called RN F to go help with the transfer. The DON stated LVN P described Resident #95 as lethargic and was not herself according to the CNA. The DON stated she asked for Resident #95's vitals and told LVN P to contact the Doctor. The DON said there was no change in Resident #95's condition the day before ([DATE]) and she had come down to the Christmas Party and got her gifts. The DON stated Resident #95 was not acting different and did not make any complaints. An interview and record review on [DATE] at 2:12 PM with RN A revealed the weekly skin assessment dated [DATE] indicating skin intact with no issues was not based on an actual assessment but what Resident #95 would report to her. The ADON stated she saw Resident #95 every day. On [DATE] Resident #95 was getting off the toilet, and normally did not need help. The ADON stated she talked with Resident #95 about the pain in her feet and when Resident #95 stood up she pulled up her pants and did not have anything on her skin or redness to her left. The ADON demonstrated where she could see Resident #95 skin and stated Resident #95 only had her lower back exposed. The ADON stated she did not wipe Resident #95 because she did not need the help. The ADON stated she could not see Resident #95's buttocks or peri area because Resident #95 was ready to pull her pants up, and she would not have even seen that. Interview on [DATE] at 2:37 PM, Resident #95's family member stated they were not aware Resident #95 refused skin assessments and stated facility staff did not inform them of refusals. An interview on [DATE] at 1:03 PM with CNA G revealed she was a restorative aide, and the other CNAs and the nurses would sometimes ask her to help them out. CNA G remembered it was morning, because she was going to get Resident #95 to go work out in the gym, where she normally went to do her exercises, and that was when CNA I asked her to help with the resident. She said CNA I told her that Resident #95 was weak, had had loose bowels, and she needed help with her. CNA G said they did not normally need to help Resident #95, and she knew as soon as CNA I asked for help with her, something was wrong. She said she was surprised when she saw her and knew something was not right with her. CNA G said on Saturday ([DATE]), Resident #95 was sitting in her chair, slouching, when normally she was sitting upright in her chair, and reading, or praising God. The resident told CNA G she didn't feel good. CNA G told her she was there to help clean her up. Resident #95 agreed to let her help. She immediately went and told LVN P (an agency nurse) to come right now because the resident had a big change in condition. She said that LVN P went to Resident #95 and took her vitals. Resident #95 normally did her own care, but she looked bad and she was weak and had BM on her. Soiling herself was something Resident #95 never did. CNA G said she had never seen Resident #95 naked, because normally she just got her set up for her shower and she stood outside the door while she showered herself. She said Resident #95 would shower, dress, and come out, then CNA G would go and clean up the shower. CNA G said when Resident #95 came to the facility initially, she was weak, but therapy got her better and she was self-caring after that. CNA G said she thought CNA I asked her to help on a Saturday, but on the Friday before ([DATE]) she was up, and moving around, but she did mention to her that she thought she might have a flu or something, because she was not feeling well, and she thought someone tested her for the flu. CNA G said before that Friday ([DATE]) Resident #95 was fine, and was in activities, singing along, and she had only complained on that Friday. CNA G said she saw Resident #95 playing bingo earlier that week, and she was functioning as she normally did, and carrying on her daily routine. She said the resident went from that, to on Saturday ([DATE]) too weak to care for herself. CNA G said she and the other CNA put Resident #95 on the bed to clean her up, because she was so heavily soiled. She said they tried to assist her to stand, but she could not even do that, so they laid her down, and cleaned her the best they could. She said the skin looked intact, nothing that would be a red flag to alarm them, like redness or excoriation. She said that Resident #95 was more comfortable with her than she was with most people, but nobody was getting up in there. because Resident #95 was so modest she would never allow them to spread her legs, to get to everything. CNA G said because the resident would not allow them access to her entire body she could not be 100% sure Resident #95 was 100% clean. CNA G stated Resident #95 would not let anyone clean her peri area. She said LVN P got orders to send Resident #95 to the hospital, and everyone expected her to come back. She said when the staff learned she passed away, they were shocked, and it brought everyone down. She said everyone loved Resident #95, and she missed her. CNA G said normally if someone would not let you do care, or wouldn't let you do it right, you would tell the nurse, and the nurse would document it in the notes. She said she was sometimes present when the DON did skin assessments, and she was able to describe what she herself looked for when doing care, and what the nurses did for a skin assessment, and that they documented in detail about the skin, and contacted the physician. She said when she assisted nurses, she held up legs, and all of the other body parts, any skin folds, genitalia, breasts, so the nurse could see into all of their cracks and crevices. She said if they did not report a skin concern to the nurse, something the size of a pea could turn into a big problem, and a wound could lead to a serious infection if it was not treated and could kill someone. Review of facility policy Nursing Documentation Issued: [DATE], Reviewed: [DATE], reflected 1The medical record must contain an accurate representation of the actual experience of the resident-and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions. Review of the [NAME] Procedures adopted as facility policy for Documentation: Long-Term Care retrieved on [DATE] at 9:59 AM from https://procedures.lww.com/lnp/view.do?pld=4139796&disciplineld=7169 , reflected Introduction: ( .) Accurate, detailed documentation shows the extent and quality of the care that nurses provide, the outcomes of that care, and the treatment and education that the resident still needs. It also decreases the risk of miscommunication and errors and promotes continuity of care. Documentation helps demonstrate that a nurse has applied nursing knowledge, skills, and judgment according to professional nursing standards. ( .) These records must also be complete, accurate, readily accessible, and systematically organized and must provide documentation of the resident's assessments and the care plan and services provided. ( .) Implementation: ( .) Document only the care actually provided. Don't document care, treatments, or medications that you intend to administer. ( .) Special Considerations: Never tamper with documentation or any part of the clinical record. Tampering includes ( .) inserting inaccurate information in the record ( .) Review of the policy Refusal Care or Treatment, Issued: [DATE]; Reviewed: [DATE], reflected: Policy: It is the policy of the facility to allow the resident to be informed and made aware of the risks, benefits and procedures to be used in providing treatment as well as alternatives, any, and to give Informed consent or refuse treatment. This includes the initiation of treatment and the continued application of treatment. ( .) Procedure: ( .) 4. If a resident refuses medication or treatment, the facility will notify the resident and/or the resident representative of the risks versus benefits of the refusal. a. The facility should explore the reasons for the refusal and possible alternatives with the resident and/or resident representative. ( .) 6. If the resident refuses other care activities such as bathing, the facility should speak with the resident and/or resident representative to determine if the preference or tolerance for this care activity has changed. The interdisciplinary team should work with the resident and or resident representative to develop alternative options to provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. 7. Documentation of the refusal and ( .) notifications should be present in the resident's medical record. Review of the facility policy Skin Integrity & Pressure Ulcer/Injury Prevention and Management, Effective Date: [DATE]; Revised: [DATE], reflected: Policy: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards ( .) Procedure: ( .) 2. Per regulation a standardized risk assessment tool should be completed upon admission/readmission, weekly for 4 weeks, quarterly, and as needed based upon each resident's specific needs. The standardized risk assessment tool being used is the Braden Scale ( .). The score and additional risk factors are documented on the tool. 3. A skin assessment/inspection should be performed weekly by a licensed nurse. a. Skin observations also occur throughout points of care provided by CNAs during ADL care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the Nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed. Review of the [NAME] Procedures adopted as facility policy for Skin Assessment: Long-Term Care retrieved on [DATE] at 10:05 AM from https://procedures.lww.com/lnp/view.do?pld=4138690&disciplineld=7169, reflected Critical Notes! (Facility Corporation Name) has approved the following information as an addendum to the Lippincott procedure. Please reference the Skin Integrity & Pressure Ulcer/Injury Prevention and Management policy and include the following information: - Skin inspections are performed frequently by CNAs during ADL care. Any changes or concerns are reported to nursing. -Showers may be optimal time for coordinated skin inspections. Introduction: Skin inspections offers [sic] insight into a resident's physical condition. Visual inspection of the resident's skin provides objective data; information gathered during the interview process directly from the resident or a family member in their own words, including thoughts and observations on the resident's health, provides subjective data. Physical assessment focuses on inspection and palpation. During inspection, the exposed area should be observed for color, moisture, texture, and the presence of lesions. ( .) Implementation: ( .) Assist the resident with putting on a resident gown to gain access to the resident's skin and to facilitate assessment. ( .) Inspecting and palpating the skin: - Expose the resident's skin adequately to facilitate assessment. ( .) Documentation: Document your assessment findings, including the risk assessment score and identified risk factors as well as findings communicated to other health care providers. Document teaching provided to the resident and family (if applicable), their understanding of that teaching, and any need for follow-up teaching. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:14 PM due to the above failures. The facility Administrator, DON and Regional RN were notified. The Administrator was provided the IJ template on [DATE] at 12:14 pm and a plan of removal was requested. An interview on [DATE] at 12:14 PM with the Administrator, Regional RN, and DON revealed they had been expecting an IJ to be called, and where near completion on their Plan of Removal (POR.) The DON stated that they could ask a resident if they had skin issues, and that Resident #95 was fully alert and oriented, and able to say if she was having any pain. The DON likened asking an alert and oriented resident if they had any pain to a physician asking an alert and oriented patient if they were having any issues with their skin at an appointment. The Administrator stated she could give documentation from [DATE] that the resident had a wound, but it was not a DTI or a pressure ulcer. The Regional RN stated she also reviewed the documents from [DATE], and the diagnoses contraindicated each other, and she saw the photo from before Resident #95 died. The DON stated that if Resident #95 was having pain, she would have alerted someone. She said she understood the nurse should have done the full assessment, and did not do it, but Resident #95 did not want her to, and they could not, if she did not want them to. The following plan of removal submitted by the facility was accepted on [DATE] at 2:56 PM. Plan of Remediation: [Facility Name] Re: Pressure Ulcers Failures: o The facility failed to identify and implement interventions for a pressure ulcer, that was identified in the hospital after she had been transferred to the hospital Corrective Action for Those Found to Have Been Affected by the Deficient Practice: o Identified resident no longer resides in the facility o Education will be completed regarding conducting thorough skin assessments, Braden assessments, updating care plans, documenting of refusal of resident care, and implementing resident specific interventions related to pressure ulcers. This education will be provided to all licensed nursing staff by the Director of Nurses or Regional Nurse Consultant. This training will be completed prior to staff working and by [DATE]. Identification of Other Residents Having the Potential to be Affected: o On [DATE] Infection Prevention Nurse, Director of Nurses, Staff nurse and Regional Nurse conducted a skin sweep on all residents in the facility o No negative outcomes identified o All residents that reside in the facility will have a completed skin data collection tool, Braden and updated care plan by the Infection Nurse, Director of Nurse, Staff nurse or Regional Nurse this will be completed by [DATE] Measures/Systemic Changes to Ensure the Deficient Practice does Not Recur: o The DON and IP nurse and Regional Nurse began immediate in servicing on [DATE] of current licensed nursing staff on the following and will be completed on [DATE] or prior to the staff working shifts: o Completion of a thorough skin assessment upon admission within 24 hours by charge nurse weekly o Completion of Braden assessment upon admission and then weekly X4 weeks and then monthly. o Completion of care plan upon admission and updated on any significant change o Completion of implementation of interventions upon identifying any wound areas o How to Document refusal of skin assessments by residents, notifying DON of any skin assessment refusals immediately Current licensed staff will not be allowed to work until completion of education as noted above and completed by [DATE] Ongoing Monitoring: o Director of Nurses, Infection Nurse and Regional Nurse will complete the following until substantial compliance has been achieved and maintained: o Review and documented audits for completion of weekly skin assessments for residents o Review and documented audits for completion of refusal skin sheets o Review and documented audits for completion of Braden assessments audits o Review and documented audits for care plans for residents with pressure ulcers identified o Review and documented audits for interventions for residents with pressure ulcers identified o The facility will continue to provide on-going in-services as noted above to newly hired licensed nursing staff, annually and as needed. o All components of this plan of correction will be submitted to the facility QAPI meeting and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Executive Director, Director of Nurses, IP nurse, Regional Nurse and RVP are responsible for the corrections and continued monitoring. Completion Date: [DATE]. Surveyor Monitoring: Interviews with RN B, RN F, LVN J, LVN L, RN M, LVN T, RN V, LVN W on [DATE] between 12:15 PM and 6:00 PM revealed nurses had been in-serviced on how to perform head-to-toe skin assessments, the Braden Scale (a tool for determining pressure wound risk), who to notify, and what to document, which included description of skin issues, and documenting refusals or partial skin assessments. The nurses were able to talk surveyors through a detailed description of how they would perform a skin assessment. Nurses confirmed that they knew that asking even an alert and oriented, independent resident about their skin did not constitute a skin assessment. All nurses were able to express understanding of the risks of not performing thorough skin assessments. An interview on [DATE] at 4:53 PM with RN A revealed she was in-serviced on [DATE] on skin, wound care, and abuse and neglect. She described the head-to-toe skin assessment in detail, including how to look at areas of the body which were normally not exposed. RN A stated she would look for anything abnormal about the skin, which could include rashes, raised skin, redness, pressure injuries, wounds, darkened areas, and would include inspecting bony prominences and low blood flow areas. She said it would be document[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of seven residents reviewed for medication errors. The facility failed to ensure Resident #1 got his own medications instead of receiving Resident #2's medications, which included a narcotic medication, on [DATE] by MA D. This failure could place residents at risk of medical complications, and reactions to increased dosages of medications or unfamiliar medications, including potentially death. The noncompliance was identified as PNC. The IJ began on [DATE], and ended on [DATE], as the facility had corrected the non-compliance by in-servicing all Medication Aides prior to the visit. Findings included: Review of Resident #1's face sheet, dated [DATE], reflected he was a [AGE] year-old male, most recently admitted to the facility on [DATE]. He had diagnoses of repeated falls, anxiety disorder, chronic kidney disease, diabetes, and heart disease. Review of Resident #1's admission MDS, dated [DATE], reflected he was usually able to understand others, and was understood by others. He had a BIMS score of 15, indicating intact cognition. He had no behaviors or indicators of psychosis during the assessment period but had a depression indicator score of 13 out of 27, indicating moderate depression. He used a walker and a wheelchair. He required only set-up help for eating, and substantial to maximal assistance (helper does more than half the effort) for toileting, dressing, and hygiene. He required partial to moderate assistance (helper does less than half the effort) for getting in and out of bed, moving himself in bed, and transfers. He did not receive PRN or scheduled pain medication in the past five days and reported no pain in that period. Review of Resident #2's face sheet, dated [DATE], reflected he was a [AGE] year-old male, admitted on [DATE]. He had diagnoses of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute respiratory failure, type 2 diabetes with chronic foot ulcer, urinary catheter, unspecified psychosis, paraplegia (paralysis of the lower body), hemiplegia and hemiparesis following cerebral infarction (one-sided weakness following a stroke), multiple sclerosis (an autoimmune disorder which attacks nerve cells), chronic kidney disease, neuropathy (nerve pain), heart disease, emphysema (this is a lung diseases that causes air sacs destruction), and chronic obstructive pulmonary disorder (both conditions which make breathing difficult). Review of Resident #2's quarterly MDS, dated [DATE], reflected he was able to be understood by others, and usually understood others. He had a BIMS score of 11, indicating moderate cognitive impairment. He had no indicators of psychosis, or behaviors, during the assessment period, and a depression indicator score of 16 out of 27, indicating moderately severe depression. He had range-of-motion impairment in his upper and lower extremities and used a wheelchair for locomotion. He was dependent on staff for most ADLs and movement in bed. He did not transfer, stand, or walk during the assessment period. He received scheduled and PRN pain medications in the past five days, and had frequent pain, which frequently affected his sleep and interfered with his day-to-day activities. He rated his worst pain in that period as a nine on a one-to-ten scale. Review of Resident #2's MAR for [DATE] reflected the following medications/dosages were administered to him on the morning of [DATE]. - Sertraline HCl Tablet 100 MG Give 2 tablet by mouth one time a day for depression - Ascorbic Acid Tablet 1000 MG Give 1000 mg by mouth one time a day for Supplement - Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for prophylaxis - Bumetanide Tablet 1 MG Give 1 tablet by mouth in the morning for fluid retention - Calcium Oral Tablet 500 MG (Calcium) Give 1 tablet by mouth one time a day for supplement - Cholecalciferol Oral Capsule 125 MCG (5000 UT) (Cholecalciferol) Give 1 capsule by mouth one time a day for supplement - Depakote Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day related to unspecified psychosis not due to a substance or known physiological condition - Famotidine Tablet 20 MG Give 1 tablet by mouth one time a day for acid indigestion - Flecainide Acetate Tablet 50 MG Give 1 tablet by mouth two times a day for irregular heartbeat - Gabapentin Tablet 600 MG Give 1 tablet by mouth three times a day for Neuropathy - HydrALAZINE HCl Tablet 25 MG Give 3 tablet by mouth three times a day for hypertension - Magnesium Oxide Tablet 400 MG Give 1 tablet by mouth one time a day for supplement - Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day related to essential (primary) hypertension - Multi-Vitamin/Minerals Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for Supplement - Senna Tablet 8.6 MG (Sennosides) Give 2 tablet by mouth one time a day for constipation - OxyCODONE HCl Tablet 15 MG Give 1 tablet by mouth every 12 hours for moderate to severe pain Review of Resident #1's MAR for [DATE] reflected the following morning medications were held on [DATE]: - Clopidogrel Bisulfate (Plavix) Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention -Order Date- [DATE] 2331 [blood thinner/Antiplatelet agent] - Rivaroxaban Oral Tablet 10 MG Give 1 tablet by mouth in the morning for MI-Order Date-[DATE] 2331 [blood thinner/Anticoagulant] -Duloxetine HCl Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth two times a day for depression-Order Date-[DATE] 2331. - Amlodipine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day for HTN -Order Date- [DATE] 2331. -Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime for high Cholesterol -Order Date- [DATE] 2331. - Calcium Oral Tablet 500 MG (Calcium) Give 1 tablet by mouth two times a day for Supplement -Order Date- [DATE] 1853 - Carvedilol Tablet 12.5 MG Give 1 tablet by mouth two times a day for Hypertension Hold if SBP less than 100 Order Date- [DATE] 2331 - Cilostazol Tablet 100 MG Give 1 tablet by mouth two times a day for blood thinner -Order Date- [DATE] 2331. - Finasteride Tablet 5 MG. Give 1 tablet by mouth one time a day for bladder Gloves should be worn by person handling or administering this product if they suspect or anticipate pregnancy -Order Date- [DATE] 2331. - Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 30 MG (Isosorbide Mononitrate) Give 1 tablet by mouth in the morning for Angina [chest pain] -Order Date- [DATE] 2331 - Multi-Vitamin/Iron Tablet (Multiple Vitamins-Iron). Give 1 tablet by mouth one time a day for Supplement multivitamin with iron-Ca-FAmin 27-0.4mg -Order Date- [DATE] 2331. - Pregabalin Oral Capsule 75 MG (Pregabalin). Give 1 capsule by mouth three times a day for Diabetic complication causing injury to some body nerves -Order Date- [DATE] 2331. -Rosuvastatin Calcium Tablet 20 MG Give 1 tablet by mouth one time a day for lipid control -Order Date [DATE] 2331. - Vitamin D (Ergocalciferol) Oral Capsule 50 MCG (2000 UT) (Ergocalciferol). Give 1 capsule by mouth one time a day for supplement -Order Date- [DATE] 1855. - Acetaminophen Tablet 325 MG Give 2 tablets by mouth three times a day for pain -Order Date- [DATE] 1951. Review of Resident #1's MAR for [DATE] reflected the following medications/dosages that were administered to him on of [DATE] at 12:05 PM: - Naloxone HCl Injection Solution 0.4 MG/ML (Naloxone HCl) Inject 1 ml intramuscularly as needed for opioid overdose until [DATE] 10:05 Inject in shoulder or thigh. Repeat after 3 minutes if no or minimal response. Order Date- [DATE] 1205. Also known as Narcan. Review of Resident #1's MAR for [DATE] reflected his 8:00 PM medications were not administered, because he was sleeping. Review of nursing progress note by LVN C, dated [DATE] at 5:08 PM, reflected [direct quotation] Type: Event Note LATE ENTRY Note Text: The resident was in therapy when this nurse was notified, therefore this nurse immediately ran down to report the incident to the DON. ADON and Administrator. When we arrived back to the floor therapy had just brought him back and reported him being sluggish. Upon getting a assessment and verifying ABC's and he was lethargic and could not answer basic questions. The doctor was notified and orders were given to administer IM injection of Narcan 2mg and check vitals every 15 mins x 1 hour and if no improvement send him to the ER. Review of Resident #1's vital signs during the acute assessment reflected the following. Blood pressure, oxygen saturation, and Pulse vital summary: [DATE] at 11:40 AM BP 142/76, pulse 108, oxygen 98 % by LVN C, [DATE] at 11:55 AM BP 131/71, pulse 105, oxygen 96 % by LVN C [DATE] at 12:10 PM BP 152/76, pulse 105, oxygen 97 % by LVN C [DATE] at 12:25 PM BP 151/73, pulse 105, oxygen 97 % by LVN C [DATE] at 12:40 PM BP 140/75, pulse 105, oxygen 96 % by LVN C [DATE] at 01:40 PM BP 136/76, pulse 96, oxygen 97 % by LVN C In an interview with Resident #1 on [DATE] at 11:20 AM, Resident #1 was in his room in his bed. He stated he could not recall being given any wrong medications. He stated he cannot remember a lot of things. He stated that he was fine and had no complaints. An interview on [DATE] at 11:29 with CNA A revealed she heard about Resident #1 having to have Narcan [this is a medication that is used to treat narcotic overdose in an emergency] through the grapevine on [DATE]. She heard a med aide gave a resident the wrong medicine. She said she thought the med aide was working upstairs at the time of this interview, but she was agency or something and she did not know her. She said the nurse on duty when it happened was the same one on duty at the time of this interview. She said she had never heard of anyone getting the wrong medications here before. She said Resident #1 seemed a little sleepy and needed a little more help in the shower on [DATE], but he seemed more like his normal self on the day of this interview. She did not know if he was sent to the hospital, and she thought the CNA on duty that day was CNA B, and she might know more. In an interview with MA D on [DATE] at 12:16 PM, MA D stated that on Monday [DATE], she had given Resident #1 medicine that belonged to Resident #2. She stated that therapy had come to get Resident #1 and at the time she had popped into a medicine cup all morning medicines belonging to Resident #2, but at the time, she thought it belonged to Resident #1. She stated she forgot whose medications they were, but she thought they belonged to Resident #1. She stated after administering the medicine that she had in the cup to Resident #1, he went to therapy. She stated she then took out medications that she thought were for Resident #2 and popped them into another medicine cup and took them to Resident #2 but Resident #2 refused to take them. MA D stated that after Resident #2 refused to take the pills she went to nurse LVN C to let her know that Resident #2 was refusing his medicine saying it was not his. MA D stated that she was confused on which resident was in bed A, and which one was in bed B. She stated that she should have asked someone to verify the bed arrangements so that she could have been sure that bed A was for Resident #1, and it was close to the entry way and bed B belonged to Resident #2 and it was close to the window. She stated she realized that she had given Resident #1 medicine that should have been given to Resident #2. MA D stated that she was confused by trying to rush before therapy took Resident #1, and not being familiar with the residents, the bed numbers, and having only worked at the facility for 4 days. MA D stated she was very upset (observed crying), and she had messed up. MA D stated she had a one-on-one in-service after the incident with the DON and that she had done a medication check return demonstration. MA D stated that the medication error was reported to the nurse, the DON, the ADON, and the Administrator the same day it happened. She stated that she worked the rest of her shift after being in-serviced. She stated that when giving medication it was important to remember the medication rights practice (Right patient, Right medication, Right dose, Right route, Right time). She stated the risk to Resident #1 getting medicine that did not belong to him was adverse medication reactions and she stated he could have died. An interview on [DATE] at 12:26 PM with LVN C revealed that on [DATE] she had been on the opposite end of the hall when MA D came to her and said she could not get a resident to take his medications. She went with her to check, and when she walked in Resident #1's bed was empty, and Resident #2 was in his bed. Resident #2 said those were not his medications, because there were not enough pills in the cup to be his medications. She asked MA D who she was trying to give the meds to, and she and MA D looked at each other and she could see on her face she realized she had given Resident #2's medications to Resident #1. MA D said she had given Resident #1 the other medications before he went downstairs to therapy, and she thought the beds were switched and the A bed was by the window. LVN C went to get the DON Immediately and told her that they needed to go to therapy to check on Resident #1. She, the DON, and the ADON were heading downstairs to therapy room to find Resident #1, at the same time, therapy was bringing Resident #1 back upstairs. She stated she did not know which therapist it was and the DON got the physician on the phone and explained that a med error had occurred while she (LVN C) took Resident #1's vital signs. She said Resident #1 was starting to seem confused and lethargic, but his vital signs were not bad. She said therapy had said he was lethargic, but she felt he was more sleepy than lethargic. The physician ordered two doses of Narcan, 2ml, and for her to check vitals every 15 minutes for one hour. She administered the Narcan, which was 1ml in each of the two bottles, and he became more alert, more easily roused, and less confused. His vital signs remained stable. She said the medication they were most concerned about was oxycodone every 12 hours. She said Resident #1 did occasionally take Tylenol with codeine, but nothing as strong as Resident #2. At first the Administrator asked her to count MA D out (count the medications in the cart so MA D could end her shift.) The DON said MA D was about to go on her lunch, and she did not need to count to go out to lunch. Then she came back and worked the rest of her shift. LVN C said after it happened, she did not know what happened with MA D, in terms of training or disciplinary action. It was her responsibility to oversee her on the floor, but the rest was the administration's responsibility for disciplinary action. She said she thought MA D was from an agency, and [DATE] was the first time she had ever seen her. She said MA D seemed to know what she was doing, and had asked her questions when she had them, but after this incident she was breaking down and crying a lot. She said MA D was very upset, because she knew that her error could have caused the resident to die. Resident #2 understood what happened, and he did receive his medications and did not have any problems with it. An interview on [DATE] at 1:19 with PT E revealed she had worked with Resident #1 on [DATE]. She said he was not as alert as usual, and not able to participate a lot, so they cut the treatment short. His blood pressure was a little low, she thought 91 or 92, over 62. She thought a few minutes of exercise might raise it, so they worked on his legs, and it came up a bit, but went right back down. At that point he said he was not dizzy or anything, but he was seeing blue stars, so she took him to his nurse, who checked his vitals and put him back in bed. She said she saw him on [DATE] working with OT F and he was not able to follow instructions, and was easily roused, but was dozing. She said she was PRN, so she had limited contact with Resident #1, but she had worked with him before. She said he was usually talkative and engaged more. She said it did not happen often that a resident who was normally able to participate showed up not able to. An interview on [DATE] at 1:33 PM with OT F revealed when he worked with Resident #1 on [DATE]. He required maximum assistance to sit on the edge of his bed, and the week before that it took only contact assistance. He said Resident #1's family member had watched him in therapy the previous week, he had a great day, and he barely had to touch him. OT F said that Resident #1 had been experiencing some decline in the week before that day. He said when he went to Resident #1's room to get him, he was sitting on the edge of his bed to taking his medication. He stated after that he took Resident #1 to therapy and for the first 30 minutes, he was OK, but then, in addition to requiring maximum assistance, he started falling asleep and could not follow all of the commands. He said he took his blood pressure, which was fine. He thought maybe the resident was having blood sugar problems, which he did sometimes and, which he could not check. He went to look for a nurse downstairs and did not see one. He took Resident #1 upstairs, and an aide told him that Resident #1 had taken the wrong medications. They put him in bed, and the nurse came, and PT O left the room. He was not sure what happened after that. He heard they might send him out to the hospital, but he did not know if they did. He said on [DATE] Resident #1 did much better in therapy. An interview on [DATE] at 2:08 PM with the Administrator revealed Resident #1 was going to therapy and MA D was in the middle of passing Resident #2 his medications, and because the therapist was waiting, and said they needed to take Resident #1 right then she stopped and dispensed Resident #1's medication and. She stated MA D was going to give Resident #2 his medications afterwards. She accidentally gave Resident #1 the wrong medications. She said it was an honest mistake, and they pulled her off the floor. She stated they did an in-service with her, and a medication competency, to make sure she knew what she was doing, and that she knew how to identify a resident before she administered medications. She said they did an in-service with all the other Medication Aides. She said MA D was borrowed from a sister facility. ADM stated Resident #1 did not suffer any harm from the incident. An interview on [DATE] at 2:18 PM with the DON revealed the medication error happened on Monday [DATE] between 11 AM and 12 PM. She stated the nurse informed her the med aide got two residents medicines mixed up. She stated Resident #1 received Oxycodone and that was the only medication that was concerning at the time. The DON stated she went upstairs to assess Resident #1 while LVN C was on the phone with the doctor. She stated the doctor ordered Narcan to be given to Resident #1 to help reverse the effects of the oxycodone (an opioid medication). She stated vitals were given to the doctor as they were being done and she could not recall the exact numbers. She stated once Resident #1 was stable and easier to arouse the doctor gave orders to monitor Resident #1 for one hour checking his vitals every 15 minutes. The DON stated that they investigated MA D's medication error right away and did training and a competency check with her. They did in-services with the other aides right away, so there was no reason to suspend her. She said the new medication aides normally went through training with another medication aide to make sure they understood what they were doing, their job description, and she and their HR also do their parts of the orientation. She went over the expectations they needed to meet with each new aide. She in-serviced the new staff, and she in-serviced all of her staff a lot. She said when they come in from a sister facility, they did orient them to the floor, but they already have the same training as they would in this facility. She said MA D had not worked in this building in the time she had been here. She said the medication aides just did the med count with the oncoming aide at the end of the shift but did not round like nurses and CNAs did. She said getting the wrong medication could potentially result in death, lethargy, or having a reaction to the medication. An interview on [DATE] at 3:56 PM with MA G revealed he worked in the facility PRN. He said he had not heard about the incident with the wrong medication given, but when he arrived for his shift, the DON did a training and competency with him on medication pass, and she talked about the Five Rights (of medication administration). He said he did not work at the facility often, because he was in nursing school, so they did it right when he came in on this day. He said she went over a lot of things, including how to make sure you erre giving the right resident the medication, giving it the right way, and how to know when to hold it. He said that he would talk to the resident, and ask them, and if they were not able to answer or seemed confused, he would check the picture in the computer, and check with the nurse, or another staff member who would know the resident. He said he would ask the nurse or other staff if he had any questions about anything. An interview on [DATE] at 3:59 PM with MA H revealed that she worked with Resident #1 on Monday after the medication incident. MA H stated that Resident #1 appeared very drowsy, and she asked the night nurse RN M if they could hold his night shift medications that were due on her shift at 8PM. She stated that Resident #1 medicines were not given on nightshift on [DATE]. MA H stated that it was her responsibility to always double and triple check residents' identity before medication administration. She stated that being careful during medication administration was vital. She stated the risk to a resident receiving the wrong medication was reaction a to medicine and other serious medicine effects. An interview on [DATE] at 4:52 PM with the Administrator and the DON revealed the DON had gone over the med pass in-service on [DATE] in-person with MA D, MA H, and MA I, and talked to the other aides, and was still talking to them about it. The DON said she was planning to start having the medication aides round at shift change, but today they were still just doing the count. She said she felt like they did what they could when it happened and did not think of what happened as actual harm. When asked what might have happened if Resident #2 had not been alert and oriented and able to identify that he was being offered the incorrect medications, which alerted them immediately to the error, the DON said that even if Resident #2 had not noticed the medications were wrong, they would have noticed his change in condition and sent him to the hospital. She said after they identified the error LVN C was taking Resident #1's vitals and writing them down and providing them to the physician. She said the physician had come to check on Resident #1 on [DATE], and the resident was doing well, and there were no new orders. The DON said she had checked on him in the middle of the night and they talked about him in their morning meeting. The DON said that the risk to the resident when getting the wrong medications depended on the interventions put in place, and they put the intervention of the Narcan in place. She stated the risk could potentially include actual harm, and that a resident could get sick or die. The Administrator confirmed that she had self-reported the medication error, after the state surveyors started asking about it, and they were doing competency checkoffs with all of the medication aides, as well as the in-servicing they had already done when it happened. An interview on [DATE] at 11:21 AM with Resident #2 revealed MA D was a temp and he had not seen her before. He said they did not really have regular people passing medications like they used to have, and the people often changed. Resident #2 said he knew all of his medications, and he knew the ones she tried to give him on [DATE] were not his. He said his roommate's (Resident #1) medications probably would not have hurt him any if he had taken them, but they probably would not have helped him either, and his medications played havoc with his roommate. He said Resident #1 was normally kind of confused and that he seemed more normal on [DATE] than he had for a couple of days after he got the wrong medications. Resident #1 said he did get his own medicine that morning ([DATE]) and did not have any problems because of what happened. He said that the medication aides did make mistakes on his medications sometimes, and it happened fairly regularly (he was not able to say when it last happened before this, or how often it happened), but he always checked, them so he knew he was getting the right ones. An interview on [DATE] at 12:22 PM with the NP revealed the facility had reached out to the Physician on [DATE] about Resident #1, not her, but she had checked on the resident on [DATE] and [DATE]. She said she did not know what acute monitoring the facility was doing, but they should have been monitoring him routinely for 24 hours. She said that during the acute monitoring the vital signs the facility sent her were good, except for a little bit of tachycardia (fast heartbeat), which was normal for Resident #1. She said even if the staff had not become aware of the medication error, any time they noted a change in condition, like altered mental status, they would have notified the physician, and they would do STAT vitals, ordered STAT labs as appropriate to the situation, and taken any precautions ordered by the physician. She said she did not know exactly what Resident #1's orders were at the current time, but he had been in and out of the hospital, and in the facility before, and had taken narcotic medication, so his body was not naïve to narcotics. She said the strength difference could make a difference in how it affected someone, but he would not be as likely to have to have a serious reaction as someone who had not taken any medications of the same type in the past year or so. She said any time they started someone on a medication, especially a geriatric patient, she started them on a low dose , and went slow in working their way up (raising the dosage), so of course they would be concerned about it, and monitor him and act as needed, but she did not feel it was likely to have caused lasting harm to him. An interview on [DATE] at 12:49 PM with the Physician revealed the facility did notify her about the medication error with Resident #1, and she had been made aware of the IJ. She said with narcotics, any negative effect would be relatively immediate. She said when Narcan was given, it's done (the effect is immediate), and it puts a stop to the possibility that a person will stop breathing because of the narcotic. She said she only knew Narcan to work for the opiates, not the other medications, and she listed a long list of possible symptoms. She stated the mixture of those medications could do anything under the sun, and that the combination of the psych meds and opiate could potentially cause a full-on out-of-body experience in some people, and that you never knew how an individual would respond to them. She said with the narcotic 99% of people would just be sleepy, and the next thing they watched for, which would only be .08% would be an allergic reaction. She said when someone got the wrong medication, and they sent them to the hospital, all they do was observe them. The Physician stated that many people got the same combination of medications (narcotic and psych med), and there would be no reason to try to get it out of (by inducing vomiting) someone who got them mistakenly. She said she told them to keep monitoring him, because in the emergency room all they would do would be monitor him for signs of anything besides sleepiness. She felt that even if they had not caught the medication error, she did not feel the resident would have experienced a negative long-term outcome. She said the most likely outcome would be somnolence (sleepiness), and an allergic reaction could have been possible, which was a serious thing, but also only had a very small chance of occurring. She said she was not downplaying the situation, and that this was a serious thing, and they gave him a serious drug (Narcan), but she felt that it was highly unlikely he would have suffered any serious consequences of the error. Review of facility's policy titled Medication-Related Errors, revision date [DATE], reflected . read in part .3.2 Dose Error-dispensing to the resident of a dose that is greater than or less than the amount ordered by physician/prescriber. 3.4. Rate Error-Dispensing the incorrect rate of administration of the medication to a resident other than the amount ordered by physician/prescribe. 3.6. Frequency Error- dispensing to the residents of a medication at an incorrect interval of administration other than that is ordered by physician/prescriber. 3.8. Medication Error-Dispensing to the resident a medication other than that ordered by the physician/prescribe. 3.9. Resident/Facility Error-Dispensing to a resident or facility other than the one intended. 3.12. Monitoring Error-Failure to review a prescription regimen for appropriateness.4. In the event of an administration error, facility staff should follow facility policy relating to medication administration errors . Interviews from [DATE] at 12:00 PM to [DATE] at 10:00 AM with MA D, MA G, MA H, MA I, MA J, and MA K revealed they had all been in-serviced on medication administration topics, including making sure the correct resident received the medications, by the DON, and were able to answer questions about the five rights of medication administration (right patient, right drug, right time, right dose, and right route). They stated they would ask the nurse about any concerns or questions they had about anything, including the identity of a resident, in order to be absolutely sure they were giving the medications to the right person. They all explained how they would go about identifying a resident and knew how to do so if the resident was able to be interviewed reliably, or if they were not. They were all able to explain potential risks of a resident receiving medications which were meant for another resident. Review of an undated staff roster, and an interview on [DATE] at 1:50 PM with the DON and the Administrator reflected MA D, MA G, MA H, MA I, MA J, and MA K were the current medication aides at the facility, and there was one medication aide listed on the roster who was no longer an employee of the facility. Review of staff competency for MA D reflected medication administration check off completed on [DATE]. Review of an in-service signature form dated [DATE] reflected the DON in-serviced MA D, MA G, MA H, MA I, MA J, and MA K on Medication Administration, how to identify the resident before administering medications, and medical discrepancies. Review of a Medication Pass Review competency check-off sheet for MA D, dated [DATE] reflected she passed all areas of the competency and was able to demonstrate passing medications per physician orders. The competency included Was a system of resident identification utilized? Review of Medication Pass Review competency check-off sheets dated [DATE] for MA G, MA H, MA I, MA J, and MA K reflected they all passed the review, and were able to demonstrate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers that were avoidable for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. 1. The facility failed to perform weekly skin assessments for Resident #1 from 09/25/2023 to 10/07/2023. 2. The facility failed to notify the physician during the admission process of the resident's pressure ulcers to obtain wound treatments, and failed to obtain orders to help prevent facillity acquired pressure ulcers to develop. Resident #1 developed stage 3 pressure ulcers to right heel, left heel, and right buttock, one deep tissue injury to right ankle, one deep tissue injury to left ankle, and two deep tissue injury to left foot while at the facility. An Immediate Jeopardy (IJ) was identified to have existed from 09/25/2023 to 10/13/2023. The IJ was determined to be at past non-compliance as the facility had implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures could place residents with impaired skin integrity at risk of developing wounds or deterioration of existing wounds and a decrease in quality of life. Findings included: Review of Resident #1's face sheet, dated 11/09/2023, revealed a [AGE] year-old-male who admitted [DATE] from an acute care hospital and discharged on 10/07/2023 to an acute care hospital. Resident #1's diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #1's admission assessment, dated 09/25/2023, completed by LVN A, reflected in part, skin was not intact and areas marked included bruise, skin tear and open area/wound. The assessment indicated his upper mid back had opening area from boney prominence, left elbow with weeping scabbed area, back of left hand had weeping open area, other with left arm 7 cm skin tear and other right back of shoulder area with no description. Further review of the admission assessment revealed Resident #1 required maximum assist x2 with toileting, transfers and x1 for bed mobility. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #1 did not have unhealed pressure ulcers/injuries and did have skin tears. Review of Resident #1's care plan, dated 09/26/2023, revealed he was at risk for a break in skin integrity with interventions that included clean and dry skin after each incontinent episode, and treatment as ordered. No other interventions were documented. The open areas/skin tears found on admission were not documented. Review of Resident #1's physician orders, and TAR from 09/25/2023 through 10/07/2023 revealed no assessment, treatment or monitoring for skin. Review of Resident #1's Braden scale (for predicting pressure sore risk), dated 09/25/2023, revealed a score of 12 indicating high risk. Review of Resident #1's Braden scale, dated 10/06/2023, revealed a score of 12 indicating high risk. Review of Resident #1's nursing notes dated 10/07/2023 written by RN B revealed At approximately 11:40am a change of condition was noted in resident mental status while conducting an assessment, open area on right heel also noted, NP notified and tele-visit conducted with resident, while [family member] at bedside, based on NP's evaluation of resident order received to transport resident out for more extensive evaluation. Further review of nursing notes from 09/25/2023 revealed no documentation of skin issues, assessment, or treatment for skin. Record review of Resident #1's EHR revealed no evidence that the resident's pressure ulcers were clinically unavoidable. Review of ED to hospital admission records dated 10/07/2023 through 10/27/2023, revealed Resident #1 had a diagnosis of severe anemia. Review of ED HPI dated 10/07/2023 at 2:15 pm reflected in part. [AGE] year-old male with a past medical history of hypertension, arthritis, lung cancer in remission who presents for failure to thrive via EMS. Patient is at a SNF and was brought in by [family member's] request. Per EMS, the [family member] state he was not getting proper care for his right foot and ankle. Patient has a pressure ulcer on his ankle that is bandaged Pressure wound right heel. Dried Necrosis. Further review of hospital records revealed the following wounds: - forearm anterior; right. Assessed on 10/07/2023. Present on admission. 2 cm Length by 3 cm Width by 2.2 cm depth. Wound bed color: pink; yellow; bright red; black. Texture: spongy. Slough (yellow-tan dead tissue): 1-25%. Eschar (brown or black, dry, dead tissue): 1-15%. Granulation: 26-50%. Wound thickness: full thickness. Moderate drainage. Odor: none. - forearm anterior; left. Assessed on 10/07/2023. Present on admission. 4 cm Length by 2.2 cm Width by 0.2 cm depth. Wound bed color: pink. Texture: non-blanching; spongy. Slough: none. Eschar: none. Granulation: 76-100%. Wound thickness: partial thickness. Moderate drainage. Odor: none. - Pressure Injury Heel; right. Assessed on 10/07/2023. Present on admission. 5.5 cm Length by 4 cm Width by 0.2 cm depth. Wound bed color: bright red. Texture: spongy. Slough: none. Eschar: 1-25%. Granulation: 26-50%. Epithelialization: 26-50%. Wound thickness: Eschar Cover. Drainage: small. Odor: none. Pressure injury staging: U - Pressure injury Back: Mid. Assessed on 10/07/2023. Present on admission. 2 cm Length by 1.8 cm Width. Wound bed color: black; purple. Texture: spongy; non-blanching. Slough: none. Eschar: none. Granulation none. Epithelialization: none. Wound thickness: full thickness. Drainage: none Odor: none. Pressure injury staging: DTPI - Pressure injury Scapula: Right. Assessed on 10/09/2023. Present on admission. 2 cm Length by 1.8 cm Width. Wound bed color: purple; black. Texture: non-blanching. Slough: none. Eschar: none. Granulation: none. Epithelialization: none. Wound thickness: full thickness. Drainage: none Odor: none. - Pressure injury Buttocks: Right. Assessed on 10/09/2023. Present on admission. 5 cm Length by 3 cm Width by 2.3 cm depth. Wound bed color: pink. Texture: spongy; non-blanching. Slough: none. Eschar: none. Granulation: 76-100%. Epithelialization: none. Wound bed exposed: Adipose Exposed. Wound thickness: full thickness. Drainage: small. Odor: none. Pressure injury staging: 3. - Pressure injury Foot: Lateral. Assessed on 10/09/2023. Present on admission. Wound bed color: purple; black; pale. Texture: spongy. Drainage: none. Pressure injury staging: DTPI. Notes: two DTI wounds on left lateral foot: distal measures 2.8 by 2, proximal 2.5 by 1.8. - Pressure injury Ankle left: lateral. Assessed on 10/09/2023. Present on admission. 2 cm Length by 1.8 cm Width by 0.1 cm depth. Wound bed color: purple; bright red. Texture: firm; Leathery. Slough: 1-25%. Eschar: 51-75%. Granulation: none. Epithelialization: none. Wound thickness: eschar cover. Drainage: none. Odor: none. - Pressure injury Ankle right: anterior. Assessed on 10/09/2023. Present on admission. 4 cm Length by 10.5 cm Width by 0.1 cm depth. Wound bed color: purple. Texture: non-blanching. Slough: none. Eschar: none. Granulation: none. Epithelialization: none. Wound bed exposed structure: Tendon Exposed. Drainage: none. Pressure injury staging: DTPI. - Pressure injury Ankle left: anterior. Assessed on 10/09/2023. Present on admission. 2 cm Length by 1.8 cm Width by 1 cm depth. Wound bed color: purple. Texture: non-blanching. Slough: none. Eschar: none. Granulation: 76-100%. Epithelialization: none. Drainage: none. Odor: none. Pressure injury staging: DTPI. - Pressure injury Heel: Left. Assessed on 10/09/2023. Present on admission. 2 cm Length by 2 cm Width by 0.1 cm depth. Wound bed color: purple; black. Texture: non-blanching. Slough: none. Eschar: none. Granulation: none. Epithelialization: none. Wound thickness: full thickness. Drainage: moderate. Odor: none. Pressure injury staging: Unstageable. Skin assessment performed per consult. Patient presents with multiple wounds, some due to previous falls (seen on previous admission) and new pressure injuries to bilateral ankles, feet, heel, back, sacrum and buttocks. Review of hospital documentation clarification by hospital MD dated 10/21/2023 revealed patient has an unstageable pressure injury located on bilateral heels .patient has Stage 3 pressure injury on right scapula and right buttock. Interview with Resident #1's family member on 11/08/2023 at 9:27 am revealed Resident #1 was currently in another nursing facility. The family member stated RN B took pictures of Resident #1's foot, did a virtual visit with the doctor and showed the wound on his right heel and was sent to the hospital. The family member stated he was not turned while at the facility and did not have pressure ulcers before he admitted . A request was made with the Executive Director from sister facility on 11/09/2023 at 11:17 am, of all documentation related to Resident #1's skin assessments, treatment, and wound care. She stated the DON was getting all wound care notes together. Interview with the DON on 11/09/2023 at 1:58 pm revealed she talked with LVN A who admitted Resident #1. The DON stated LVN A said she did the initial assessment but could not initiate treatment since Resident #1 did not come with orders, and she stayed within her scope as an LVN and could not initiate treatment. The DON stated she in-serviced the nurses to call the doctor and get some kind of treatment order. The DON stated Resident #1 had skin tears on his back and on both arms, but no other skin issues were documented. The DON stated she did not remember that Resident #1 had wounds. When asked why the weekly skin assessment was not completed, the DON stated when LVN A identified the skin issue, it should have triggered a weekly skin assessment in the EHR. The DON stated the nurses were responsible for completing weekly skin assessments, and it automatically populated. The DON stated had LVN A completed the wound observation tool and skin assessment tool, it would have populated every week to be completed. The DON stated she was responsible to oversee that assessments were completed. The DON stated part of their Plan of Correction (facility was cited for not completing skin assessments on 10/13/2023) was getting CNAs involved with their shower sheets. So when any skin issue was brought to her attention, depending on the type of wound, they would get a wound consult from Dr. [Name]. The DON stated the wound doctor came every Monday. The DON stated nurses from a sister facility have been over to do the skin assessments and she hired a nurse, LVN G, who would start Monday (11/13/2023) to round with the wound doctor and to complete weekly skin assessments. The DON stated the risk for not completing assessments would be a negative outcome for the resident, worsening of wounds. Phone interview on 11/09/2023 at 10:53 am, LVN A stated Resident #1 had bruising, scabs, bony prominences almost like bone would stick out, it was not open but had a foam dressing to protect it. She said she put the dressings back like they were because they should not be open. LVN A stated Resident #1 had quite a bit of issues going on with his skin. LVN A stated when a resident admitted , she completed an initial assessment, took vitals, and if there was a dressing, she would take it off and see what was underneath and put them back on just like they were, finish charting, then send to the provider to get any updated orders. She stated LVN's could not initiate orders and could not diagnose so she would give the assessment to the provider, and they would initiate any type of dressing. LVN A stated skin assessments should have completed weekly. She stated each nurse had their own assessments due, the day shift nurses have even numbered rooms and the night nurses have odd numbered rooms. LVN A stated there was no wound nurse and the former ADON would round with the wound doctor but she left in September. LVN A stated she had been in-serviced on wound treatment, technique and have competency checks about every 6 months. Phone interview on 11/09/2023 at 11:27 am, RN B stated he thought Resident #1 had a couple of wound orders, and treatment for both of his arms, but he could not really remember and would have to look at the MAR. He stated he could not remember if Resident #1 had something on his bottom. He stated Resident #1's family member talked about a small reddened area on one of his heels; it was not open. He stated a week before Resident #1 went to the hospital, Resident #1 would not eat and would not let staff feed him. RN B stated a tele-visit with the NP was on done on Saturday or Sunday and the NP said to send him out. RN B stated when a resident admitted , a head-to-toe assessment was done and usually get a skin report (from the hospital) when they come, but nurses were supposed to do an assessment. He stated if he identified something new like a reddened or opened area, he would let the physician know and get an order. He stated nurses were responsible for doing skin assessments every week. Phone interview on 11/09/2023 at 11:39 am with LVN C was unsuccessful. Surveyor left voicemail and no return call was received. Interview on 11/09/2023 at 12:02 pm, the DON stated since they audited on 10/13/2023, 3 residents were found to have new skin issues but no pressure ulcers. She stated the RDCS, Nurse management at the facility and from the sister facility, completed the skin sweep. The DON stated a skin assessment should be done upon admission for a new admit, and at the time of the assessment, the nurse should document any open areas or any issues and complete the wound observation tool in the EHR. She stated that automatically triggers the skin review every week. She stated if any skin issues were found, then the nurse should contact the NP or doctor to get orders. She stated her expectation was for nurses to assess and measure wounds, and then notify the doctor. She stated Resident #1's family member did not make her concerns known about the wound on the ankle to her. Interview on 11/09/2023 at 12:31 pm with the RDCS revealed she did not remember Resident #1, had not talked with Resident #1's family member, and Resident #1's nurse note said he was sent out for change of condition and she believed RN B sent him out over the weekend. She stated the process to ensure skin assessments were completed for new residents admitted to the facility was the skin assessment was populated on admission, and if there was a skin issue, a wound observation tool was generated in the EHR. She stated the nurses completed those on a weekly basis. She stated the DON was overseeing that they were completed, and she oversaw the DON. She stated it turned red on the EHR if it was late or missing. She stated since the nurses did the wound treatments, she and the DON in-serviced nurses on pressure ulcers and treatments. Interview on 11/09/2023 at 2:31 pm with CNA D revealed she was from agency, and it was her first time working at the facility. She stated if she saw any redness/skin breakdown/new skin issue she would report it to the nurse. Interview on 11/09/2023 at 2:34 pm with CNA E revealed she was from agency and it was her first time working at the facility. She stated if she saw any redness/skin breakdown/new skin issue she would report to the nurse. Interview on 11/09/2023 at 2:36 pm with CNA F revealed he had worked at the facility for 3 weeks. He stated if he saw any redness/skin breakdown/new skin issue he would inform the nurse, because they needed to do an intervention, and call the wound doctor to see what was going on. Interview on 11/09/2023 at 1:25 pm with DON and LVN A by phone revealed LVN A stated she did not remember speaking with a provider about Resident #1 but had sent in her assessment and did not receive any treatment orders from the NP or doctor. The DON stated if LVN A gave report to the provider, and they did not give any recommendations and there was no treatment orders to move forward with. The DON stated LVN A should have documented any treatment provided. Record review of in-service dated 10/12/2023 revealed nurses were educated on pressure ulcers - changing and dressings to wounds, following MD orders, and weekly skin completion. Record review of weekly skin audit dated 10/27/2023 and 11/02/2023 revealed weekly skin assessments completed. Record review of facility policy titled Documentation & Assessment of Wounds revised 03/31/2023 reflected in part: to guide the associates and licensed nurse in the assessment of wounds to include pressure ulcer/injuries, venous, arterial, diabetic, dehisced surgical wounds, and other (not otherwise specified) Procedure 1. A wound assessment/documentation is required to occur at a minimum 'weekly'. Nurses performing the treatment would perform a prn assessment/documentation if noted change has occurred i.e., wound has healed/resolved, appears infected, or appears to have declined. It may not be practical for the 'weekly' assessment to occur on the 7th day deadline due to dressing not required to be changed on due date, wound round or MD schedule changes, follow-up appointments, or resident's refusal. For those purposes would obtain wound assessment/documentation prior to if able or within the calendar week to maintain assessment and documentation compliance. Record review of facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management revised 08/25/2021 and reviewed 03/31/2023 revealed in part: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy, Continent Nurses Society) . Procedure 1. A comprehensive skin inspection/ assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present . 3. A skin assessment /inspection should be performed weekly by a licensed nurse 4. Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services . a) skin inspections with particular attention to bony prominences; e) minimize injury due to shear and friction through proper positioning, transfers, and turning schedules (if indicated); . 5. Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: a) reposition at least every 2-4 hours (per NPIAP standards) as consistent with overall patient goal and medical condition; b) utilize positioning devices to keep bony prominences from direct contact; c) ensure proper body alignment when side-lying; d) heel protection/suspension if indicated; .