**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 1 (Resident #16) of 3 residents reviewed for abuse. The facility failed to protect Resident #16 from physical abuse. Resident #16 was pushed off of his bed, onto the floor by CNA J during incontinence care on 11/29/23. The non compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 11/29/23 and ended on 11/29/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for abuse and could lead to serious injury, serious harm, serious impairment, pain, and/or mental anguish. Findings included: Review of the facility Abuse, Neglect, molestation, and Misappropriation Policy dated 11/1/2022 stated that: A. The use of verbal, sexual, physical and mental abuse .of the resident is strictly prohibited. Review of Resident #16's face sheet, dated 12/7/23, revealed he was a [AGE] year-old male, initially admitted to the facility on [DATE] with diagnoses that included: Cerebrovascular Disease, Muscle Weakness, Dementia without Behavioral Disturbance, Primary Insomnia, and Benign Neoplasm of the Colon (A mass of tissue growing inside of the colon). Review of Resident #16's quarterly MDS assessment dated [DATE], revealed he had a BIMS score of 03: severe cognitive impact on decision making. The resident had the ability to usually understand, with clear speech, with no documented behaviors and required extensive assistance of one staff member to complete ADL's. Review of Resident # 16's Plan of Care dated 12/4/23 reflected 1. [Resident #16] had been assessed for actual Trauma symptoms as manifested by substantiated abuse from staff CNA. Interventions included: Provide and ensure a safe environment by providing consistent caregivers and provide Psych Eval as ordered/when needed. 2. [Resident #16] is physically aggressive to staff during cares (hit, fights). Interventions included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. 3. [Resident #16] has potential psychosocial well-being problem related to traumatic event (substantiated abuse from staff member 11/29/23. Interventions included: Consult with pastoral care, social services, increase communication between resident/family/caregivers about care and living environment. Explain all procedures and Treatments, Medications, results of labs/tests, Condition, All changes, rules, Options. Review of CNA J's time sheet revealed that CNA J worked on 11/28/23 to 11/29/23 during the 10:00 PM to 6:00 AM shift on the secure unit (300 wing). Further review of CNA J's time sheets showed that CNA J did not work at the facility after 11/29/23. Review of CNA K's time sheet revealed that CNA K worked on 11/28/23 to 11/29/23 during the 10:00 PM to 6:00 AM shift on the secure unit (300 wing). Review of RN M's time sheet revealed that RN M worked on 11/28/23 to 11/29/23 during the 10:00 PM to 6:00 AM on the secure unit (300 wing). Interview and observation on 12/5/23 at 12:05 PM with Resident #16 revealed that the resident did not have any visible bruising on any areas of observable skin. The resident stated he did remember his fall, he stated he was just fine, he felt safe at he the facility and that the staff all treated him nicely. Interview on 12/5/23 at 12:23 PM with CNA L revealed she had worked with Resident # 16 for several months now and that he was generally very happy. She had never had any problems with Resident #16 being combative while administering cares but that she could see him possibly being that way if he was disorientated late at night. Interview on 12/06/23 at 12:42 PM with ADM revealed it had been reported to him that Resident #16 had a fall around 5:00 AM on 11/29/23. The ADM reviewed video of the incident at 12:50 PM on 11/29/23 as was his normal course of investigating falls on the secure unit. He stated after reviewing the video and discerning that CNA J had pushed Resident #16 out of his bed intentionally, he immediately called CNA J to his office. CNA J reported continues to report that Resident #16 rolled out of bed.The ADM and CNA J watched the video together and CNA J then confessed to pushing Resident #16 out of his bed to the floor, CNA J was immediately terminated. He stated that he immediately called the police, then conducted 5 Safe Surveys on the secure unit and ordered the nursing staff to conduct immediate skin assessments of all residents on the secure unit. No negative findings were discovered for either the Safe Surveys or the skin assessments. He stated that he started in-service trainings for all secure unit staff that afternoon and completed in-service training for all staff within 24 hours of discovering the incident. He stated that the facility had had an extra nurse on the secure wing since discovery of the incident. Interview on 12/6/23 at 10:00 AM with SW revealed that she had spoken to Resident #16 right after the incident on 11/29/23 and that Resident #16 had expressed he did not feel it had been a big deal, that he still likes all of the staff and the other residents at the facility. Interview and review of video on 12/06/23 at 12:51 PM with DON revealed that DON identified CNA J on the video (no audio available) at timestamp 11/29/23 4:47 AM starting to administer cares for Resident #16. 5:01 AM rolled Resident #16 onto his left side, while Resident #16 was holding on to the side rail. At timestamp 11/29/23 at 5:02 AM CNA J turned resident to right side to move pad under resident. At time stamp 11/29/23 at 5:03 AM Resident #16 appeared to try to help initially, then the resident turned reaching out towards with an open hand and fist and while kicking towards CNA J. CNA J switched to the other side of bed, Resident #16 then moved himself onto his back, with knees up and perpendicular to his shoulders. Resident #16 was then observed to weakly kick CNA J on her right shoulder with his right foot. CNA J roughly pushed Resident #16's extended right leg away from her with enough force to move the resident from laying on his back to laying on his left side. At timestamp 11/29/23 at 5:04:03 CNA J was observed placing both hands on the residents back and pushed/shoved Resident#16 off the left side of the bed to the floor, where Resident #16 landed on his right side. At timestamp 11/29/23 at 5:04:09 AM, Resident #16 observed laying on his right side on the floor, CNA J was then observed immediately going to the resident room door. At timestamp 11/29/23 at 5:04:43 AM Resident #16 was observed still on the floor of his room, Resident #16 then pulls his bed towards him. DON identified CNA K at timestamp 11/29/23 at 5:05:04 AM. CNA K is observed in the video entering the room by himself. CNA K moved the bed away from the resident. At timestamp 11/29/23 at 5:05:36 AM CNA J re-enters room. DON identified RN M at timestamp 11/29/23 at 5:06:36 AM, RN M was observed entering Resident #16's room. RN M is then observed in the video doing an initial assessment of Resident #16 on the floor and is then observed with CNA K lifting Resident #16 from the floor back to his bed. CNA J was observed at the end of Resident #16's bed. RN M is then observed completing Resident #16's assessment. DON then stated that it was very fortunate Resident #16 sustained no immediate injuries. Interview on 12/6/23 at 1:22 PM with CNA K revealed he had been working the night of the incident with Resident #16. He stated he had never observed any actions by CNA J that caused him concern. He stated that Resident #16 could sometimes be combative during administering of care, but he was able to redirect Resident #16's behavior. He stated that he had received immediate in-services the next day for Abuse and neglect and Resident Behaviors. Interview on 12/7/23 at 3:38 PM with RN M revealed that CNA J had reported to her that Resident #16 had had a fall while she had been administering cares to Resident #16. RN M reported that after she had gone to resident #16's room and assessed Resident #16 that CNA J described that Resident #16 had been aggressive during administration of cares and that he had fell out of the bed. RN M stated that she had worked with CNA J for several months. She stated that she had never received any complaints about CNA J from residents or other staff and that none of CNA J's actions had ever given her any pause for concern. She stated that she had cared for Resident #16 the next night shift and he had never complained of or exhibited any signs of pain. She stated that the previous shifts nurse had reported that Resident #16 had not complained of or exhibited any signs of pain. Review of the facility's Provider Investigation Report, incident date 11/29/23 and reported to HHSC on 11/29/23, reflected an incident category of abuse. The reports description of the allegation revealed, CNA J reported to the nurse that Resident #16 rolled out of bed during care. As part normal fall investigation routine when DON and ADM review the fall video, it showed memory care unit Resident #16 becoming combative punching and kicking the CNA during care .CNA deliberately pushed hard on residents back and rolled him out the bed. The reports Investigations findings revealed Confirmed. The reports description of injury revealed no injuries. The reports description of assessment revealed Head to toe assessment. The reports Provider Action Taken Post-Investigation revealed X-ray results were all negative. Resident does not show signs of distress. Abuse in-service and Resident Behavior during Care in-service completed. Employee interviews and statements were completed on 11/29/23. The ADM was informed of the PNC IJ and completed the IJ Template on 12/07/23 at 12:42 PM. Monitoring of the facility's implemented actions that corrected the non-compliance prior to entry included: Review of CNA J's employee file revealed that she had no prior criminal history, and her license was unobstructed. Three references were positive in nature and the CNA had completed all orientation training . Record review of skin assessment sheets dated 11/29/23 for all residents on the secure wing (300 Hall) revealed that there were no unexplained bruising, abrasions or scratches for all residents assessed. Review of the in-service training dated 11/29/23 reflected Abuse and Neglect and Combative Residents/Abuse. Both identified types of abuse, procedures for reporting abuse and interventions for combative residents. Interviews were conducted on 12/07/23 from 1:53 PM to 12/07/23 at 3:38 PM with licensed nursing staff and CNA staff, CNA B, CNA D, CNA N, LVN F, LVN P, and RN M. The nursing staff and CNA's were able to accurately summarize the facility's reporting policy and procedure related to abuse/neglect to include unknown bruising, injuries of unknown origin reporting and documenting and interventions with combative residents. Observations on the secure unit from 12/05/23 at 9:00AM to 12/07/23 at 2:00 PM revealed that the facility had scheduled two nurses on the secure unit at all times/shifts. Review of CNA J's Separation Report dated 11/29/23 revealed CNA J was terminated immediately for Gross Misconduct, and terminated due to resident abuse. The document was signed by both the ADM and DON on 11/29/23. Review of the facility's incident/accident reports and grievance files for the last three months revealed no relevant findings to the incident. The non compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 11/29/23 and ended on 11/29/23. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult the resident's physician when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of five residents reviewed for resident rights. 1. The facility failed to ensure Resident #1's physician was notified of a critical CMP (comprehensive metabolic panel) lab with a glucose with a reading of 480. 2. The facility failed to notify Resident #1's physician, when her blood sugar reading was 453 on 07/01/23 and out of parameters. On 07/21/23 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/22/23, 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 Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place residents at risk of not having their physician consulted of changes in condition timely, resulting in a delay in medical intervention and decline in health or possible worsening of symptoms, including death Findings included: Review of Resident #1's significant change MDS assessment dated [DATE] reflected she was an [AGE] year old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included diabetes, non-Alzheimer's dementia (the loss of cognitive functioning -thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech, caused by brain damage), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hemiplegia (paralysis of one side of the body), malnutrition (lack of proper nutrition), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), GERD (a condition in which the stomach contents move up into the esophagus), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher) and dysphagia (swallowing difficulty). Resident #1 had no speech and was rarely/never understood and had adequate vision and hearing. Resident #1 had long and short term memory problems and severely impaired cognitive decision making skills. Resident #1 has signs/symptoms of delusions, including inattention and altered level of consciousness with vigilance (startled easily with sound or touch), but had no indicators of psychosis, wandering or rejection of care. Resident #1 was totally dependent on staff for all ADLs and had upper and lower range of motion impairment on both sides of her body and was incontinent of bowel and bladder. Resident #1 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Resident #1 did experience significant unplanned weight loss in the past six months and used a feeding tube, was given insulin injections and anticoagulant medication. Review of Resident #1's care plan dated 02/05/23 reflected she had Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and was at risk for signs and symptoms and complications. Interventions were to monitor/document for side effects and effectiveness, dietary consult for nutritional regimen, fasting serum blood sugar as ordered by doctor, if infections was present than consult doctor regarding any changes in diabetic medications, inspect feet daily, and monitor/document/report signs and symptoms of hypoglycemia and infection to any open areas. Review of Resident #1's physician orders for June 20223 and July 2023 reflected a one-time order, CBC, CMP, A1C (start date 06/28/23 and ordered by PHY B), Insulin Lispro Injection Solution 100 UNIT/ML-Inject as per sliding scale: if 151-200 = 3 Units; 201-250 = 6 Units; 251-300 = 9 Units; 301-350 = 12 Units; 351-400 = 15 units Give insulin and call MD if BS >400, subcutaneously before meals (start date 04/25/23), Levemir Subcutaneous Solution-Inject 30 unit subcutaneously one time a day (06/22/2023). Review of Resident #1's CMP lab result on 06/29/23 reflected it was a critical result with her blood glucose at 480 (Reference range is 81 to115). The lab result electronically documented on the form that RN J was notified on 06/29/23 at 11:38 PM. Review of Resident #1's July 2023 MAR/TAR reflected on 07/01/23 at 8:54 AM, agency LVN D took Resident #1s blood sugar and it was 453. There was no indication any insulin was given at that time as the nurse did not reflect that sliding scale was administered and did not document any administration of insulin in a nursing note or an assessment of the resident. The MAR/TAR reflected, Inject as per sliding scale: .351-400=15 units; Give insulin and call MD if BS>400. There was no evidence through nursing documentation that the physician was notified, or the resident was assessed for any decline in condition. Resident #1's MAR/TAR reflected her last 24 hours of blood sugar readings prior on 06/30/23 were 252 at 7:00 AM, 218 at 11:30 AM and 385 at 4:30 PM. Review of nursing progress notes for Resident #1 on 06/29/23 through 07/02/23 revealed neither the physician or nurse practitioner were notified of the resident's critical lab result on 06/29/23 and of the elevated blood glucose reading on 07/01/23. Review of NP E's progress note on 07/03/23 reflected she had a face to face visit with Resident #1 and a facility nurse reported that the resident was not acting her normal self. NP E noted no moaning or facial grimaces during care/turning per the facility nurse. Resident #1 was seen lying in bed with eyes closed. She did not have any response to verbal, tactile stimuli and sternal rubs. Her respirations were even and unlabored and she did not appear to be in acute distress and her vital signs were stable. The NP ordered Resident #1 to be sent to the ER for altered mental status. NP E documented she reviewed a CMP lab dated 06/21/23 that she had previously ordered where Resident #1's glucose was 355. There was no evidence she reviewed the critical lab from 06/29/23 ordered by PHY B when her blood sugar was 480. Requested EMS Run Report and hospital records on 08/07/23, but investigator was unable to obtain the records. An interview with the overnight nurse RN J on 07/20/23 at 4:39 PM revealed she remembered Resident #1, but she did not remember receiving a critical lab result for the resident on 06/20/23 on the overnight shift. RN J stated, When a lab is critical, the lab company, you know I haven't received any, but they would call the facility, I haven't received any in, god, a long time, and they do call, ask who you are. Then the nurse would immediately call the doctor. Even overnight, you still attempt to call them and see. You would notify the family and you need to hear from the doctor. RN J stated the harm of not following up would be the resident could go into a coma if she began to have symptoms of hyperglycemia and it was not treated. RN J stated the facility nurse who the lab company contacted was responsible for documenting it in a progress note and complete a change in condition form, call the doctor and document results and complete vitals. RN J stated, I don't remember getting any such call, .As a nurse, communication is how I know if labs need to be followed up on the 24-hour form .I haven't gotten a call for a critical lab in a long time. I am talking way long time, three to six months. An interview with the DON on 07/20/23 at 2:15 PM revealed Resident #1 passed away in the hospital and she did not know what her was the cause of Resident #1's death. The DON confirmed as she observed Resident #1's nursing progress notes, an order for a CMP on 06/29/23 but she did not see where the critical lab was reported in the system by the nurse. The DON stated if a lab company could not reach a nurse at the facility for a critical lab, they can contact her and the treatment nurses 24/7. The DON stated the receiving nurse for the critical lab was supposed to call the nurse practitioner if it was Monday through Friday and the Physician if it was Saturday and Sunday and notify them and the nurse then would write a progress note and notate any new orders. Regarding Resident #1's high blood sugars on the MAR, the DON stated if a blood sugar was over 400, what should have happened was the doctor should have been notified, the resident given insulin and then her blood sugar re-checked and if it was still high, then notify the doctor and he would have decided to send her to the ER or not. The DON stated even if Resident #1's blood sugar readings the rest of that day were not under 400, it meant the insulin was not working properly. She stated the issue with using agency nurses was they did not know where a resident's baseline was at for vitals and condition. The DON stated the nurse who made the error (LVN D) with the lack of notification and documentation when Resident #1's blood sugar was over 400 was an agency nurse. She said when a resident's blood sugar was over 400, the nurse would also need to complete a significant event form for high blood sugar reading in e-charting software and that information would be reflected the next morning for management to review. An interview with the DON on 07/20/23 at 4:26 PM revealed, We dropped the ball with [Resident #1]'s lab. The DON confirmed the critical lab notification was made by the lab at 11:38 PM and the lab documented RN J was the person notified. The DON stated RN J was a facility nurse and knew the protocols, but the DON could not find a progress note or anything on the 24-hour report. She said the morning nurse (LVN A) did not remember being notified of a critical lab during change of shift report the next day. The DON stated again, I hate to admit it, but the ball was dropped. She said RN J was a seasoned nurse and had been at the facility for six years and knew better. The DON stated ADON H was going to start in-services on critical lab readings, who to notify and what steps to take. A follow up interview with the DON on 07/20/23 at 4:58 PM revealed she had pulled the hard copy of the 24-hour report that the nurses wrote on versus the one in the e-charting system and pointed to where RN J had hand-written on the 24-hour report for the shift on 06/29/23, that Resident #1's lab results were in, and the NP was notified. The DON stated, But she did not indicate it was a critical lab and she did not do the proper follow up notifications and receive orders as to how to proceed. The DON stated she was unaware of this error prior to investigator intervention. Review of the facility's 24-hour report for the overnight shift on 06/30/23 reflected revealed a hand written note that the nurse practitioner was notified of labs, next to Resident #1's name. The DON had verified in an earlier interview that it was the handwriting of RN J. An interview with NP E on 07/20/23 at 6:47 PM revealed she was unaware of the critical lab result for Resident #1 on 06/29/23 and she did not see any documentation where PHY B was notified either. NP E stated she rounded every Monday at the facility and last time she saw Resident #1 was on 07/03/23 and saw the critical lab and the resident did not look good to her, She stated Resident #1 was not responding and usually would moan when moved, but this time she did not. She did a sternal rub and Resident #1 still would not open her eyes, so she sent her to the ER. NP E stated her visit was three days after the critical lab result came in. NP E stated, They should notify us of critical lab results, but not all of them are doing it. We cannot check everyone's labs all the time, that is why we have the nurses let us know, so we can adjust the insulin. She said if she had seen Resident #1's critical lab and she was not in the condition she had been in, she would have just adjusted her insulin. Regarding the high blood sugar reading on 07/01/23, NP E stated even though Resident #1's blood sugar was high, she was on sliding scale to cover it, but she did not see any documentation where the resident's blood sugar was re-checked, and the nurse did not document that she gave insulin. NP E stated she wanted the nurses to contact her if a resident's blood sugar was over 400 and there was a sliding scale protocol. She stated, If it is way higher, we give insulin to lower it. I want them to call me if over 400, we have a sliding scale protocol. If it is way higher, we give extra insulin to lower it. NP E stated high blood sugar could cause a resident to go into diabetic ketoacidosis (develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy.) and then a coma but she felt that the issue was not Resident #1's high blood sugar that caused the change in condition but could not be sure. An interview with PHY B on 07/21/23 at 10:30 AM revealed he did not receive a call from the facility to notify him of Resident #1's critical lab result. He said he knew Resident #1 well and she was in a very debilitated condition and had a recent stroke. PHY B stated Resident #1 had short and long acting insulin, so even though the facility did not notify him of the critical lab or blood sugars over 400, she was still covered for any sugar abnormalities. However, PHY B stated with critical labs, the nurse needed to be looking at signs and symptoms and if the blood sugar was more than 400/450 or something like that, they are supposed to call him, or the NP and they could make changes. PHY B stated, Like if 500, they call me and I know I am covering the insulin and sometimes I know someone is a brittle diabetic, like in her case, then what we do, if persistently going up and we add another 5 or 6 units of insulin short acting on top of sliding scale, then they would check again in four hours to make sure the glucose is covered. PHY B stated hyperglycemia above 800 could cause altered mental status, but not around 400. He said Resident #1's body was used to the high blood sugar. PHY B stated Resident #1 was sent to the hospital because she was unresponsive, it was not the blood sugar. In our mind, she had a stroke. Attempted interview with LVN D on 07/21/23 at 2:21 was unsuccessful. A voicemail was left with a request to return investigator's call. An interview with the DON on 07/22/23 at 2:19 PM revealed she talked to RN J about not reporting the critical lab for Resident #1 the night prior and RN J admitted that she forgot that she had received the lab notification, which was in contradiction to what she stated during the investigator's interview. RN J told the DON that she told another nurse working at that time that Resident #1 had a critical lab because it was that resident's nurse. However, RN J did not document that she notified that nurse of the critical lab and when the DON asked the other nurse about it, she said she was never notified of the critical lab. The nurse was only notified by a screen shot that a lab was completed for Resident #1, but the whole lab could not be seen. The DON stated, The critical values were not communicated at that point. So I have taken the necessary steps with her as well. The DON felt the IJ occurred because of documentation. She said the critical lab was not reported and the hand-written note on the 24-hour report was not accurate. She said it was human error. The DON stated that going forward, the facility nursing management would add spot checks to monthly nursing audits and the ADON would oversee that critical lab notifications were done and documented in the resident records. Review of the facility's policy titled, Lab and Diagnostic Test Results, revised November 2018, reflected, .Identifying Situations that Warrant Immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: -Whether the physician has requested to be notified as soon as result is received, -Whether the result should be converted to a physician regardless of other circumstances, -Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable of improving, or there are no previous results for comparison; .Options for Physician Notification: 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent, a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment records needs review or clarification. The facility Administrator received the IJ template on 07/21/23 at 12:58 PM. The Plan of Removal (POR) was accepted on 07/21/23 at 5:23 PM and reflected: Plan for Removal-[Facility Name] / July 21, 2023 The Texas Department of Health and Human Services entered [Facility Name] on July 21, 2023. During their investigation, an IJ (Immediate Jeopardy) was cited on 7/21/23 at approx. 12:50pm regarding Resident Rights r/t Physician Notification of Change in Condition. The Facility failed to ensure that a physician was notified of a critical lab value for one resident on 6/29/23. F580- Plan of Removal All nurses, to include agency staff, will be in-serviced on the following: o Inservice to include SBAR for critical labs. o Inservice for critical lab reporting and documentation. On 7/20/23, the Director of Nursing began in-services with 2-10 shift nurses. The nursing leadership team also began calling nurses who were not on-shift at that time for verbal education and to provide immediate action and compliance. Any non-agency nurses who have not completed in-services will do so prior to the beginning of their next shift. All currently staffed nurses will not be allowed to work until completing competency. Agency nurses will be required to review in-services, located in a binder at nurse's station, prior to start of their shift. Compliance will be monitored by the DON daily with notification provided to any new agency nurse prior to start of their shift. The DON will provide all staffed nurses with a competency quiz to confirm understanding of in-services listed above. Quizzes will be completed prior to any staffed nurse working another shift, until all nurses have completed the competency. No nurse will work a shift until competency is completed. The nurse involved, [RN J], to be terminated effectively immediately by Administrator on 7/21/23. A daily audit tool will be utilized to monitor for critical labs and documentation of such including timely reporting to provider. This audit tool will include monitoring on the weekends. DON and ADON will complete an immediate audit of critical labs will be completed on 7/21/22, going back to 6/21/23, in order to confirm proper notification and documentation were completed and to ensure there are no active resident health or safety concerns related to lab services. On 7/20/23, an Ad Hoc QAPI meeting was held with the leadership team for root cause discussion. It was determined that the notification to physician was not completed per policy. PIPs will be initiated for physician notification with all in-services and audit tools attached for review in monthly QAPI. Administrator will host weekly Ad Hoc QAPI meetings to assist in monitoring audit tools and in-service tracking. The audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly x2 or until substantial compliance is met. Findings will be corrected in real time and discussed monthly at QAPI by the interdisciplinary team. Monitoring interviews for the Immediate Jeopardy were started on 07/22/23 at 1:00PM with nursing staff across all three shifts , including weekdays and weekends, from the nursing, administration. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to physician notification of critical labs, documentation protocol, and expectations for elevated blood sugar over 401: ADON H, LVN I, LVN K, RN P, LVN Q, LVN M, RN N, RN O, DON and ADM. Monitoring and review of all new lab results from 07/21/23 through 07/24/23 for all facility residents reflected two results came in for two different residents and were both abnormal, not critical. Proper notifications were made to the MD/NP and documentation was completed per facility protocol. The facility's ADM was notified the IJ was removed on 07/22/23 at 3:31 PM. While the Immediate Jeopardy was removed on 07/22/23, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #1) of three residents reviewed for quality of care. 1. The facility failed to assess and intervene for a potential change in condition or decline when Resident #1's had a critical CMP (comprehensive metabolic panel) lab with a glucose with a reading of 480. 2. The facility failed to ensure that when Resident #1's blood sugar was 453, that the physician was notified and it wss unclear if the resident received insulin. On 07/21/23 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/22/23, 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 Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk for potential delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Review of Resident #1's significant change MDS assessment dated [DATE] reflected she was an [AGE] year old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included diabetes, non-Alzheimer's dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech, caused by brain damage), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hemiplegia (paralysis of one side of the body), malnutrition (lack of proper nutrition), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), GERD (a condition in which the stomach contents move up into the esophagus), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher) and dysphagia (swallowing difficulty). Resident #1 had no speech and was rarely/never understood and had adequate vision and hearing. Resident #1 had long and short term memory problems and severely impaired cognitive decision making skills. Resident #1 has signs/symptoms of delusions, including inattention and altered level of consciousness with vigilance (startled easily with sound or touch), but had no indicators of psychosis, wandering or rejection of care. Resident #1 was totally dependent on staff for all ADLs and had upper and lower range of motion impairment on both sides of her body and was incontinent of bowel and bladder. Resident #1 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Resident #1 did experience significant unplanned weight loss in the past six months and used a feeding tube, was given insulin injections and anticoagulant medication. Review of Resident #1's care plan dated 02/05/23 reflected she had Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and was at risk for signs and symptoms and complications. Interventions were to monitor/document for side effects and effectiveness, dietary consult for nutritional regimen, fasting serum blood sugar as ordered by doctor, if infections is present than consult doctor regarding any changes in diabetic medications, inspect feet daily, and monitor/document/report signs and symptoms of hypoglycemia and infection to any open areas. Review of Resident #1's physician orders for June 20223 and July 2023 reflected, CBC, CMP, A1C (start date 06/28/23 and ordered by PHY B), Insulin Lispro Injection Solution 100 UNIT/ML-Inject as per sliding scale: if 151-200 = 3 Units; 201-250 = 6 Units; 251-300 = 9 Units; 301-350 = 12 Units; 351-400 = 15 units Give insulin and call MD if BS >400, subcutaneously before meals (start date 04/25/23), Levemir Subcutaneous Solution-Inject 30 unit subcutaneously one time a day (06/22/2023). Review of Resident #1's CMP lab result on 06/29/23 reflected it was a critical result with her blood glucose at 480 (Reference range is 81 to115). The lab result electronically documented on the form that RN J was notified on 06/29/23 at 11:38 PM. Review of Resident #1's July 2023 MAR/TAR reflected on 07/01/23 at 8:54 AM, agency LVN D took her blood sugar, and it was 453. There was no indication that any insulin was given at that time as the nurse did not reflect that sliding scale was administered and did not document any administration of insulin in a nursing note or an assessment of the resident. The MAR/TAR reflected, Inject as per sliding scale: .351-400=15 units; Give insulin and call MD if BS>400. There was no evidence through nursing documentation that the physician was notified, or the resident was assessed for any decline in condition. Resident #1's MAR/TAR reflected her last 24 hours of blood sugar readings prior on 06/30/23 were 252 at 7:00 AM, 218 at 11:30 AM and 385 at 4:30 PM. Review of nursing progress notes for Resident #1 on 06/29/23 through 07/02/23 revealed neither the physician or nurse practitioner were notified of the resident's critical lab result on 06/29/23 and of the elevated blood glucose reading on 07/01/23. Review of NP E's progress note on 07/03/23 reflected she had a face to face visit with Resident #1 and a facility nurse reported that the resident was not acting her normal self. NP E noted no moaning or facial grimaces during care/turning per the facility nurse. Resident #1 was seen lying in bed with eyes closed. She did have any response to verbal, tactile stimuli and sternal rubs. Her respirations were even and unlabored and she did not appear to be in acute distress and her vital signs were stable. The NP ordered Resident #1 to be sent to the ER for altered mental status. NP E documented she reviewed a CMP lab dated 06/21/23 that she had previously ordered where Resident #1's glucose was 355. There was no evidence she reviewed the critical lab from 06/29/23 ordered by PHY B when her blood sugar was 480. Requested EMS Run Report and hospital records on 08/07/23, but investigator was unable to obtain the records. An interview with the overnight nurse RN J on 07/20/23 at 4:39 PM revealed she remembered Resident #1, but she did not remember receiving a critical lab result for the resident on 06/20/23 on the overnight shift. RN J stated, When a lab is critical, the lab company, you know I haven't received any but they would call the facility, I haven't received any in, god, a long time, and they do call, ask who you are. Then the nurse would immediately call the doctor. Even overnight, you still attempt to call them and see. You would notify the family and you need to hear from the doctor. RN J stated the harm of not following up would be the resident could go into a coma if she began to have symptoms of hyperglycemia and it was not treated. RN J stated the facility nurse who the lab company contacted was responsible for documenting it in a progress note and complete a change in condition form, call the doctor and document results and complete vitals. RN J stated, I don't remember getting any such call, .As a nurse, communication is how I know if labs need to be follow up on the 24-hour form .I haven't gotten a call for a critical lab in a long time. I am talking way long time, three to six months. An interview with the DON on 07/20/23 at 2:15 PM revealed Resident #1 passed away in the hospital and she did not know what her cause of death was. The DON verified she observed in Resident #1's nursing progress notes, an order for a CMP on 06/29/23 but she did not see where the critical lab was reported in the system by the nurse. The DON stated of a lab company could not reach a nurse at the facility for a critical lab, they can contact her and the treatment nurses 24/7. The DON stated the receiving nurse for the critical lab was supposed to call the nurse practitioner if it was Monday through Friday and the Physician if it was Saturday and Sunday and notify them and the nurse then would write a progress note and notate any new orders. Regarding Resident #1's high blood sugars on the MAR, the DON stated if a blood sugar was over 400, what should have happened was the doctor should have been notified, the resident given insulin and then her blood sugar re-checked and if it was still high, then notify the doctor and he would have decided to send her to the ER or not. The DON stated even if Resident #1's blood sugar readings the rest of that day were under 400, it still meant that the insulin was not working properly. She stated the issue with using agency nurses was they did not know where a resident's baseline was at for vitals and condition. The DON stated the nurse who made the error (LVN D) with the lack of notification and documentation when Resident #1's blood sugar was over 400 was an agency nurse. She said when a resident's blood sugar was over 400, the nurse would also need to complete a significant event form for high blood sugar reading in e-charting software and that information would be reflected the next morning for management to review. An interview with the DON on 07/20/23 at 4:26 PM revealed, We dropped the ball with [Resident #1]'s lab. The DON confirmed the critical lab notification was made by the lab at 11:38 PM and the lab documented RN J was the person notified. The DON stated RN J was a facility nurse and knew the protocols, but the DON could not find a progress note or anything on the 24-hour report. She said the morning nurse (LVN A) did not remember being notified of a critical lab during change of shift report the next day. The DON stated again, I hate to admit it, but the ball was dropped. She said RN J was a seasoned nurse and had been at the facility for six years and knew better. The DON stated ADON H was going to start in-services on critical lab readings, who to notify and what steps to take. Review of the facility's 24-hour report for the overnight shift on 06/30/23 reflected revealed a hand written note that the nurse practitioner was notified of labs, next to Resident #1's name. The DON had verified in an earlier interview that it was the handwriting of RN J. A follow up interview with the DON on 07/20/23 at 4:58 PM revealed she had pulled the hard copy of the 24-hour report that the nurses wrote on versus the one in the e-charting system and pointed to where RN J had hand-written on the 24-hour report for the shift on 06/29/23, that Resident #1's lab results were in and the NP was notified. The DON stated, But she did not indicate it was a critical lab and she did not do the proper follow up notifications and receive orders as to how to proceed. The DON stated she was unaware of this error prior to investigator intervention and was just discovering it. An interview with NP E on 07/20/23 at 6:47 PM revealed she was unaware of the critical lab result for Resident #1 on 06/29/23 and she did not see any documentation where PHY B was notified either. NP E stated she rounded every Monday at the facility and last time she saw Resident #1 was on 07/03/23 and saw the critical lab and the resident did not look good to her, She stated Resident #1 was not responding and usually would moan when moved, but this time she did not. She did a sternal rub and Resident #1 still would not open her eyes, so she sent her to the ER. NP E stated her visit was three days after the critical lab result came in. NP E stated, They should notify us of critical lab results, but not all of them are doing it. We cannot check everyone's labs all the time, that is why we have the nurses let us know, so we can adjust the insulin. She said if she had seen Resident #1's critical lab and she was not in the condition she had been in, she would have just adjusted her insulin. Regarding the high blood sugar reading on 07/01/23, NP E stated even though Resident #1's blood sugar was high, she was on sliding scale to cover it, but she did not see any documentation where the resident's blood sugar was re-checked, and the nurse did not document that she gave insulin. NP E stated she wanted the nurses to contact her if a resident's blood sugar was over 400 and there was a sliding scale protocol. She stated, If it is way higher, we give insulin to lower it. I want them to call me if over 400, we have a sliding scale protocol. If it is way higher, we give extra insulin to lower it. NP E stated high blood sugar could cause a resident to go into diabetic ketoacidosis (develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy) and then a coma, but she felt that the issue was not Resident #1's high blood sugar that caused the change in condition but could not be sure. An interview with PHY B on 07/21/23 at 10:30 AM revealed he did not receive a call from the facility to notify him of Resident #1's critical lab result. He said he knew Resident #1 well and she was in a very debilitated condition and had a recent stroke. PHY B stated that Resident #1 had short and long acting insulin, so even though the facility did not notify him of the critical lab or blood sugars over 400, she was still covered for any sugar abnormalities. However, PHY B stated with critical labs, the nurse needed to be looking at signs and symptoms and if the blood sugar was more than 400/450 or something like that, they are supposed to call him, or the NP and they could make changes. PHY B stated, Like if 500, they call me and I know I am covering the insulin and sometimes I know someone is a brittle diabetic, like in her case, then what we do, if persistently going up and we add another 5 or 6 units of insulin short acting on top of sliding scale, then they would check again in four hours to make sure the glucose is covered. PHY B stated hyperglycemia above 800 could cause altered mental status, but not around 400. He said Resident #1's body was used to the high blood sugar. PHY B stated Resident #1 was sent to the hospital because she was unresponsive, it was not the blood sugar. In our mind, she had a stroke. Attempted interview with LVN D on 07/21/23 at 2:21 was unsuccessful. A voicemail was left with a request to return investigator's call. An interview with the DON on 07/22/23 at 2:19 PM revealed she talked to RN J about not reporting the critical lab for Resident #1 the night prior and RN J admitted that she forgot that she had received the lab notification, which was in contradiction to what she stated during the investigator's interview. RN J told the DON that she told another nurse working at that time that Resident #1 had a critical lab because it was that resident's nurse. However, RN J did not document that she notified that nurse of the critical lab and when the DON asked the other nurse about it, she said she was never notified of the critical lab. The nurse was only notified by a screen shot that a lab was completed for Resident #1, but the whole lab could not be seen. The DON stated, The critical values were not communicated at that point. So I have taken the necessary steps with her as well. The DON felt the IJ occurred because of documentation. She said the critical lab was not reported and the hand-written note on the 24-hour report was not accurate. She said it was human error. The DON stated that going forward, the facility nursing management would add spot checks to monthly nursing audits and the ADON would oversee that critical lab notifications were done and documented in the resident records. Review of the facility's policy titled, Nursing Care of the Older Adult with Diabetes Mellitus, revised November 2020, reflected, .Symptoms Associated with Diabetes: 1. Hyperglycemia. Uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia (blood sugars above target levels). Signs and symptoms of hyperglycemia may include the following: a. Increased thirst, b. Frequent urination, c. Sugar in the urine, d. Fatigue, e. Headache; and f. Blurred vision; 2. Diabetic ketoacidosis (DKA)(diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated, and the cells begin to metabolize fat for energy. The byproduct of fat metabolism is ketones, which build up quickly in the blood. Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention; .Complications associated with Diabetes .1. Hyperglycemia and vascular damage can lead to: a. Cardiovascular and cerebrovascular disease, including heart disease and stroke .; Glycemic Targets .6. Establish provider notification protocols. Review of the facility's policy titled, Change in Resident's Condition or Staus, revised May 2017, reflected, Our facility shall promptly notify the resident, his or her Attending Physicians, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): .d. Significant change to the resident's physical/emotional/mental condition; e. Need to alter the resident's medication significantly; .i. Specific instruction to notify the Physician of changes in the resident's condition . On 07/21/23 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/22/23, the facility remained out of compliance at a severity level of severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 07/21/23 at 12:58 PM. The Plan of Removal (POR) was accepted on 07/21/23 at 5:23 PM and reflected: Plan for Removal-[Facility Name] / July 21, 2023 The Texas Department of Health and Human Services entered [Facility Name] on July 21, 2023. During their investigation, an IJ (Immediate Jeopardy) was cited on 7/21/23 at approx. 12:50pm regarding Resident Rights r/t Physician Notification of Change in Condition. The Facility failed to ensure that a physician was notified of a critical lab value for one resident on 6/29/23. F684- Plan of Removal All nurses, to include agency staff, will be in-serviced on the following: o Inservice on policy and procedure + documentation for blood glucose monitoring o Inservice on SBAR for change in condition o Inservice on physician notification for blood glucose monitoring On 7/20/23, the Director of Nursing began in-services with 2-10 shift nurses. The nursing leadership team also began calling nurses who were not on-shift at that time for verbal education and to provide immediate action and compliance. Any non-agency nurses who have not completed in-services will do so prior to the beginning of their next shift. All currently staffed nurses will not be allowed to work until completing competency. Agency nurses will be required to review in-services, located in a binder at nurse's station, prior to start of their shift. Compliance will be monitored by the DON daily with notification provided to any new agency nurse prior to start of their shift. The DON will provide all staffed nurses with a competency quiz to confirm understanding of in-services listed above. Quizzes will be completed prior to any staffed nurse working another shift, until all nurses have completed the competency. No nurse will work a shift until competency is completed. The nurse involved, [RN J], to be terminated effectively immediately by Administrator on 7/21/23. A daily audit tool will be utilized to monitor for critical labs and documentation of such including timely reporting to provider. This audit tool will include monitoring on the weekends. DON and ADON will complete an immediate audit of critical labs will be completed on 7/21/22, going back to 6/21/23, in order to confirm proper notification and documentation were completed and to ensure there are no active resident health or safety concerns related to lab services. On 7/20/23, an Ad Hoc QAPI meeting was held with the leadership team for root cause discussion. It was determined that the notification to physician was not completed per policy. PIPs will be initiated for physician notification with all in-services and audit tools attached for review in monthly QAPI. Administrator will host weekly Ad Hoc QAPI meetings to assist in monitoring audit tools and in-service tracking. The audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly x2 or until substantial compliance is met. Findings will be corrected in real time and discussed monthly at QAPI by the interdisciplinary team. Monitoring interviews for the Immediate Jeopardy were started on 07/22/23 at 1:00PM with nursing staff across all three shifts , including weekdays and weekends, from the nursing, administration. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to physician notification of critical labs, documentation protocol, and expectations for elevated blood sugar over 401: ADON H, LVN I, LVN K, RN P, LVN Q, LVN M, RN N, RN O, DON and ADM. Monitoring and review of all new lab results from 07/21/23 through 07/24/23 for all facility residents reflected two results came in for two different residents and were both abnormal, not critical. Proper notifications were made to the MD/NP and documentation was completed per facility protocol. The facility's ADM was notified the IJ was removed on 07/22/23 at 3:31 PM. While the Immediate Jeopardy was removed on 07/22/23, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to promptly notify the ordering physician, physician assistant or nurse practitioner of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for one (Resident #1) of three residents reviewed for quality of care. The facility failed accurately document and follow up with the Resident #1's physician when Resident #1's had a critical CMP (comprehensive metabolic panel) lab with a glucose with a reading of 480. Due to the delay, the physician did not order necessary interventions. Resident #1 was admitted to the hospital three days later, where she died from unknown reasons. On [DATE] an Immediate Jeopardy (IJ) was identified. 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 Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. The facility Administrator received the IJ template on [DATE] at 12:58 PM. This failure placed residents at risk for potential delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Review of Resident #1's significant change MDS assessment dated [DATE] reflected she was an [AGE] year old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included diabetes, non-Alzheimer's dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech, caused by brain damage), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hemiplegia (paralysis of one side of the body), malnutrition (lack of proper nutrition), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), GERD (a condition in which the stomach contents move up into the esophagus), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher) and dysphagia (swallowing difficulty). Resident #1 had no speech and was rarely/never understood and had adequate vision and hearing. Resident #1 had long and short term memory problems and severely impaired cognitive decision making skills. Resident #1 has signs/symptoms of delusions, including inattention and altered level of consciousness with vigilance (startled easily with sound or touch), but had no indicators of psychosis, wandering or rejection of care. Resident #1 was totally dependent on staff for all ADLs and had upper and lower range of motion impairment on both sides of her body and was incontinent of bowel and bladder. Resident #1 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Resident #1 did experience significant unplanned weight loss in the past six months and used a feeding tube, was given insulin injections and anticoagulant medication. Review of Resident #1's care plan dated [DATE] reflected she had Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and was at risk for signs and symptoms and complications. Interventions were to monitor/document for side effects and effectiveness, dietary consult for nutritional regimen, fasting serum blood sugar as ordered by doctor, if infections is present than consult doctor regarding any changes in diabetic medications, inspect feet daily, and monitor/document/report signs and symptoms of hypoglycemia and infection to any open areas. Review of Resident #1's physician orders for [DATE] and [DATE] reflected, CBC, CMP, A1C (start date [DATE] and ordered by PHY B), Insulin Lispro Injection Solution 100 UNIT/ML-Inject as per sliding scale: if 151-200 = 3 Units; 201-250 = 6 Units; 251-300 = 9 Units; 301-350 = 12 Units; 351-400 = 15 units Give insulin and call MD if BS >400, subcutaneously before meals (start date [DATE]), Levemir Subcutaneous Solution-Inject 30 unit subcutaneously one time a day ([DATE]). Review of Resident #1's CMP lab result on [DATE] reflected it was a critical result with her blood glucose at 480 (Reference range is 81 to115). The lab result electronically documented on the form that RN J was notified on [DATE] at 11:38 PM. Review of Resident #1's [DATE] MAR/TAR reflected on [DATE] at 8:54 AM, agency LVN D took her blood sugar, and it was 453. There was no indication that any insulin was given at that time as the nurse did not reflect that sliding scale was administered and did not document any administration of insulin in a nursing note or an assessment of the resident. The MAR/TAR reflected, Inject as per sliding scale: .351-400=15 units; Give insulin and call MD if BS>400. There was no evidence through nursing documentation that the physician was notified, or the resident was assessed for any decline in condition. Resident #1's MAR/TAR reflected her last 24 hours of blood sugar readings prior on [DATE] were 252 at 7:00 AM, 218 at 11:30 AM and 385 at 4:30 PM. Review of nursing progress notes for Resident #1 on [DATE] through [DATE] revealed neither the physician or nurse practitioner were notified of the resident's critical lab result on [DATE] and of the elevated blood glucose reading on [DATE]. Review of NP E's progress note on [DATE] reflected she had a face to face visit with Resident #1 and a facility nurse reported that the resident was not acting her normal self. NP E noted no moaning or facial grimaces during care/turning per the facility nurse. Resident #1 was seen lying in bed with eyes closed. She did have any response to verbal, tactile stimuli and sternal rubs. Her respirations were even and unlabored and she did not appear to be in acute distress and her vital signs were stable. The NP ordered Resident #1 to be sent to the ER for altered mental status. NP E documented she reviewed a CMP lab dated [DATE] that she had previously ordered where Resident #1's glucose was 355. There was no evidence she reviewed the critical lab from [DATE] ordered by PHY B when her blood sugar was 480. Requested EMS Run Report and hospital records on [DATE], but investigator was unable to obtain the records. An interview with the overnight nurse RN J on [DATE] at 4:39 PM revealed she remembered Resident #1 but she did not remember receiving a critical lab result for the resident on [DATE] on the overnight shift. RN J stated, When a lab is critical, the lab company, you know I haven't received any but they would call the facility, I haven't received any in, god, a long time, and they do call, ask who you are. Then the nurse would immediately call the doctor. Even overnight, you still attempt to call them and see. You would notify the family and you need to hear from the doctor. RN J stated the harm of not following up would be the resident could go into a coma if she began to have symptoms of hyperglycemia and it was not treated. RN J stated the facility nurse who the lab company contacted was responsible for documenting it in a progress note and complete a change in condition form, call the doctor and document results and complete vitals. RN J stated, I don't remember getting any such call, .As a nurse, communication is how I know if labs need to be follow up on the 24-hour form .I haven't gotten a call for a critical lab in a long time. I am talking way long time, three to six months. An interview with the DON on [DATE] at 2:15 PM revealed Resident #1 passed away in the hospital and she did not know what her cause of death was. The DON verified she observed in Resident #1's nursing progress notes, an order for a CMP on [DATE] but she did not see where the critical lab was reported in the system by the nurse. The DON stated of a lab company could not reach a nurse at the facility for a critical lab, they can contact her and the treatment nurses 24/7. The DON stated the receiving nurse for the critical lab was supposed to call the nurse practitioner if it was Monday through Friday and the Physician if it was Saturday and Sunday and notify them and the nurse then would write a progress note and notate any new orders. Regarding Resident #1's high blood sugars on the MAR, the DON stated if a blood sugar was over 400, what should have happened was the doctor should have been notified, the resident given insulin and then her blood sugar re-checked and if it was still high, then notify the doctor and he will decided to send her to the ER or not. The DON stated even if Resident #1's blood sugar readings the rest of that day were under 400, it still meant that the insulin was not working properly. She stated the issue with using agency nurses was they did not know where a resident's baseline was at for vitals and condition. The DON stated the nurse who made the error (LVN D) with the lack of notification and documentation when Resident #1's blood sugar was over 400 was an agency nurse. She said when a resident's blood sugar was over 400, the nurse would also need to complete a significant event form for high blood sugar reading in e-charting software and that information would be reflected the next morning for management to review. An interview with the DON on [DATE] at 4:26 PM revealed, We dropped the ball with [Resident #1]'s lab. The DON confirmed the critical lab notification was made by the lab at 11:38 PM and the lab documented RN J was the person notified. The DON stated RN J was a facility nurse and knew the protocols but the DON could not find a progress note or anything on the 24-hour report. She said the morning nurse (LVN A) did not remember being notified of a critical lab during change of shift report the next day. The DON stated again, I hate to admit it, but the ball was dropped. She said RN J was a seasoned nurse and had been at the facility for six years and knew better. The DON stated ADON H was going to start in-services on critical lab readings, who to notify and what steps to take. Review of the facility's 24-hour report for the overnight shift on [DATE] reflected revealed a hand written note that the nurse practitioner was notified of labs, next to Resident #1's name. The DON had verified in an earlier interview that it was the handwriting of RN J. A follow up interview with the DON on [DATE] at 4:58 PM revealed she had pulled the hard copy of the 24-hour report that the nurses wrote on versus the one in the e-charting system and pointed to where RN J had hand-written on the 24-hour report for the shift on [DATE], that Resident #1's lab results were in and the NP was notified. The DON stated, But she did not indicate it was a critical lab and she did not do the proper follow up notifications and receive orders as to how to proceed. The DON stated she was unaware of this error prior to investigator intervention and was just discovering it. An interview with NP E on [DATE] at 6:47 PM revealed she was unaware of the critical lab result for Resident #1 on [DATE] and she did not see any documentation where PHY B was notified either. NP E stated she rounded every Monday at the facility and last time she saw Resident #1 was on [DATE] and saw the critical lab and the resident did not look good to her, She stated Resident #1 was not responding and usually would moan when moved, but this time she did not. She did a sternal rub and Resident #1 still would not open her eyes, so she sent her to the ER. NP E stated her visit was three days after the critical lab result came in. NP E stated, They should notify us of critical lab results, but not all of them are doing it. We cannot check everyone's labs all the time, that is why we have the nurses let us know, so we can adjust the insulin. She said if she had seen Resident #1's critical lab and she was not in the condition she had been in, she would have just adjusted her insulin. Regarding the high blood sugar reading on [DATE], NP E stated even though Resident #1's blood sugar was high, she was on sliding scale to cover it, but she did not see any documentation where the resident's blood sugar was re-checked and the nurse did not document that she gave insulin. NP E stated she wanted the nurses to contact her if a resident's blood sugar was over 400 and there was a sliding scale protocol. She stated, If it is way higher, we give insulin to lower it. I want them to call me if over 400, we have a sliding scale protocol. If it is way higher, we give extra insulin to lower it. NP E stated high blood sugar could cause a resident to go into diabetic ketoacidosis (develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy) and then a coma but she felt that the issue was not Resident #1's high blood sugar that caused the change in condition but could not be sure. An interview with PHY B on [DATE] at 10:30 AM revealed he did not receive a call from the facility to notify him of Resident #1's critical lab result. He said he knew Resident #1 well and she was in a very debilitated condition and had a recent stroke. PHY B stated that Resident #1 had short and long acting insulin, so even though the facility did not notify him of the critical lab or blood sugars over 400, she was still covered for any sugar abnormalities. However, PHY B stated with critical labs, the nurse needed to be looking at signs and symptoms and if the blood sugar was more than 400/450 or something like that, they are supposed to call him or the NP and they could make changes. PHY B stated, Like if 500, they call me and I know I am covering the insulin and sometimes I know someone is a brittle diabetic, like in her case, then what we do, if persistently going up and we add another 5 or 6 units of insulin short acting on top of sliding scale, then they would check again in four hours to make sure the glucose is covered. PHY B stated hyperglycemia above 800 could cause altered mental status, but not around 400. He said Resident #1's body was used to the high blood sugar. PHY B stated Resident #1 was sent to the hospital because she was unresponsive, it was not the blood sugar. In our mind, she had a stroke. Attempted interview with LVN D on [DATE] at 2:21 was unsuccessful. A voicemail was left with a request to return investigator's call. An interview with the DON on [DATE] at 2:19 PM revealed she talked to RN J about not reporting the critical lab for Resident #1 the night prior and RN J admitted that she forgot that she had received the lab notification, which was in contradiction to what she stated during the investigator's interview. RN J told the DON that she told another nurse working at that time that Resident #1 had a critical lab because it was that resident's nurse. However, RN J did not document that she notified that nurse of the critical lab and when the DON asked the other nurse about it, she said she was never notified of the critical lab. The nurse was only notified by a screen shot that a lab was completed for Resident #1, but the whole lab could not be seen. The DON stated, The critical values were not communicated at that point. So I have taken the necessary steps with her as well. The DON felt the IJ occurred because of documentation. She said the critical lab was not reported and the hand-written note on the 24-hour report was not accurate. She said it was human error. The DON stated that going forward, the facility nursing management would add spot checks to monthly nursing audits and the ADON would oversee that critical lab notifications were done and documented in the resident records. Review of the facility's policy titled, Lab and Diagnostic Test Results, revised [DATE], reflected, .Identifying Situations that Warrant Immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: -Whether the physician has requested to be notified as soon as result is received, -Whether the result should be converted to a physician regardless of other circumstances, -Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable of improving, or there are no previous results for comparison; .Options for Physician Notification: 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent, a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment records needs review or clarification. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on [DATE] at 12:58 PM. The Plan of Removal (POR) was accepted on [DATE] at 5:23 PM and reflected: Plan for Removal- [Facility Name]/ [DATE]-The Texas Department of Health and Human Services entered [Facility] on [DATE]. During their investigation, an IJ (Immediate Jeopardy) was cited on [DATE] at approx. 12:50pm regarding Laboratory Services. The Facility failed to ensure that a physician was notified of a critical lab value for one resident on [DATE]. F773- Plan of Removal All nurses, to include agency staff, will be in-serviced on the following: o Inservice to include SBAR for critical labs. o Inservice for critical lab reporting and documentation. On [DATE], the Director of Nursing began in-services with 2-10 shift nurses. The nursing leadership team also began calling nurses who were not on-shift at that time for verbal education and to provide immediate action and compliance. Any non-agency nurses who have not completed in-services will do so prior to the beginning of their next shift. All currently staffed nurses will not be allowed to work until completing competency. Agency nurses will be required to review in-services, located in a binder at nurse's station, prior to start of their shift. Compliance will be monitored by the DON daily with notification provided to any new agency nurse prior to start of their shift. The DON will provide all staffed nurses with a competency quiz to confirm understanding of in-services listed above. Quizzes will be completed prior to any staffed nurse working another shift, until all nurses have completed the competency. No nurse will work a shift until competency is completed. The nurse involved, [RN J], to be terminated effectively immediately by Administrator on [DATE]. A daily audit tool will be utilized to monitor for critical labs and documentation of such including timely reporting to provider. This audit tool will include monitoring on the weekends. DON and ADON will complete an immediate audit of critical labs will be completed on [DATE], going back to [DATE], in order to confirm proper notification and documentation were completed and to ensure there are no active resident health or safety concerns related to lab services. On [DATE], an Ad Hoc QAPI meeting was held with the leadership team for root cause discussion. It was determined that the notification to physician was not completed per policy. PIPs will be initiated for physician notification with all in-services and audit tools attached for review in monthly QAPI. Administrator will host weekly Ad Hoc QAPI meetings to assist in monitoring audit tools and in-service tracking. The audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly x2 or until substantial compliance is met. Findings will be corrected in real time and discussed monthly at QAPI by the interdisciplinary team. Monitoring interviews for the Immediate Jeopardy were started on [DATE] at 1:00PM with nursing staff across all three shifts , including weekdays and weekends, from the nursing, administration. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to physician notification of critical labs, documentation protocol, and expectations for elevated blood sugar over 401: ADON H, LVN I, LVN K, RN P, LVN Q, LVN M, RN N, RN O, DON and ADM. Monitoring and review of all new lab results from [DATE] through [DATE] for all facility residents reflected two results came in for two different residents and were both abnormal, not critical. Proper notifications were made to the MD/NP and documentation was completed per facility protocol. The facility's ADM was notified the IJ was removed on [DATE] at 3:31 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.