**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for one (Resident #1) of three residents reviewed for CPR. The facility failed to retrieve the automatic external defibrillator (AED) and initiate the basic life support sequence of events (chest compressions, airway, breathing) per the facility's Emergency Procedure-Cardiopulmonary Resuscitation Policy for Resident #1 for approximately two to seven minutes when he was found unresponsive and assessed as full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) on [DATE] at approximately 4:30 AM while awaiting EMS arrival. The facility staff called the medical examiner and the resident was unable to be revived by EMS. An IJ was identified on [DATE]. The IJ template was provided on [DATE] at 1:58 PM. While the IJ was removed on [DATE] , the facility remained out of compliance at a scope of isolated and a severity level of no actual harm that was not Immediate Jeopardy because the facility is still monitoring the effectiveness of their plan of removal. This failure placed residents at risk for harm up to and including death by the denial of all life saving measures as trained. Findings included: Review of Resident #1's electronic medical record, revealed an admission date of [DATE] and a death discharge date of [DATE], with diagnoses which included sepsis (a life threatening complication of an infection), glaucoma (a group of eye conditions that can cause blindness), encephalopathy (any brain disease that alters brain function or structure), pneumonia (infection that inflames air sacs in one or both lungs which may fill with fluid), atherosclerotic heart disease (build-up of fat in the artery walls), diabetes mellitus (too much sugar level in the blood), chronic kidney disease (kidneys are damaged and cannot filter blood well) and cardiomyopathy (difficulty for the heart to deliver blood to the body). Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old male admitted from a short-term general hospital and was scheduled discharge to the community . Resident #1 had a weight of 171 pounds and was 68 inches in height (5 foot 8 inches). Review of Resident #1's physician's order dated [DATE] revealed MD A documented a physician's order for Resident #1 to receive care as CPR/Full Code. Review of Resident #1's care plan dated [DATE], revealed, Focus: I am a Full code. Goals: My wish will carry out through next review. Interventions: call 911, discuss my code status with me/family, if found absent of vital signs initiate CPR and keep my family and MD updated on my condition. Review of facility's General Plan of Care Form signed by Resident #1 and dated [DATE] revealed Curative Plan of Care: This POC (Plan of Care) directs providers to aggressively treat all conditions and to attempt to maintain life with every available resource. This POC directs providers to hospitalize the patient if deemed necessary. Review of facility's Medical Orders for Scope of Treatment form signed by Resident #1 and dated [DATE]. Revealed: Physician Resuscitation Order: No pulse and not breathing. Attempt Resuscitation (CPR) Tube in windpipe, electrical shocks to the chest, chest compression, and IV fluids and medications. Review of Resident #1's electronic eInteract Change in Condition Evaluation document dated [DATE] at 04:50 AM revealed, A1. Mental Status Evaluation: Unresponsive. A2. Functional Status: Evaluation: no pulse detected. Review Findings and Provider Notifications: 1c. patient deceased . 4. At 04:30 AM Resident #1 found laying on stomach in room unresponsive. Notes blood on shirt, face, and floor. Notes walker ahead of resident. No pulse detected. Review of Resident #1's electronic nursing progress note dated [DATE] at 4:50 AM revealed LVN B stated CNA called this nurse to resident's room at 4:30 AM. Resident was noted to be on the floor laying on stomach. Resident unresponsive. Notes large amount of blood on resident's shirt and on the floor. Called 911 and stayed with resident. Instructed nurse to call MD A. Called DON then called the medical examiner. Called resident's Family Member C. Emergency personnel arrived immediately and pronounced the resident deceased . Family Member C and Family Member D arrived shortly after. DON arrived as well and resident released to medical examiner. Review of the facility's cell phone call log provided by the DON on [DATE] at 9:50 AM revealed a placed outgoing call to phone number 911 on [DATE] at 4:32 AM with a call duration of two minutes. Request for City E Fire Station F's 911 call response report was requested on [DATE] at 11:40 AM and was not available by time of exit on [DATE]. Interview on [DATE] at 10:46 AM with the DON she stated that during the [DATE] CPR event for Resident #1 that CPR was not initiated, the AED was not utilized, and EMS services arrived at the facility after the 911 call, approximately 2 minutes. The DON stated she did not know why the AED was not utilized and further stated that LVN B had told the DON that EMS arrived quickly. The DON stated that review of the facility's camera footage revealed that a police officer arrived at the facility first and the actual time was unknown. According to the facility camera footage EMS arrived seven minutes after the police and EMS was on site for a total of five minutes. The DON stated LVN B and RN G were involved in the CPR event for Resident #1. The DON stated it was her expectation for a resident that is full code for CPR to be initiated and to continue CPR until EMS arrives and for the AED machine to be placed on the resident. The DON stated it was her expectation for a resident that is full code and found responsive for CPR to be started even if a resident's body is assessed as stiff. Interview on [DATE] at 10:59 AM with RN G she stated on [DATE] she worked from 7:00 PM to 7:00 AM. RN G stated she was providing patient care on Hall 100 when CNA H from Hall 300 told her LVN B needed her, and Resident #1 was unresponsive. RN G stated she ran to Resident #1's room, the resident was on the floor with blood and LVN B was on the phone with 911. RN G stated she did not touch Resident #1, she did not get the crash cart (wheeled container carrying medicine and equipment for use in emergency resuscitations), she did not get the AED machine or start CPR. RN G stated she thought LVN B had already assessed Resident #1 that is why RN G did not initiate CPR. RN G stated 911 EMS arrived quickly and did not start CPR. RN G stated she helped LVN B by calling the DON and MD A. RN G stated she printed the paperwork for Resident #1 needed for EMS and that is when RN G saw on Resident #1's face sheet that Resident #1 was full code, prior to that RN G stated she did not know Resident #1's code status. RN C stated the facility's AED was stored on the facility's crash cart. RN C stated she was CPR trained by the American Heart Association. RN C stated her training included the use of an AED during CPR as soon as the AED is available. Interview on [DATE] at 12:40 PM with LVN B stated she worked on [DATE] from 7:00 PM to 7:00 AM and was assigned to Resident #1. LVN B stated on [DATE] around 4:30 AM CNA H reported to her Resident #1 was unresponsive and on the floor in his room. LVN B stated she told the CNA H to get RN G and immediately arrived at Resident #1's room. LVN B stated Resident #1 was on the floor on his stomach with red substance on his body and floor. LVN B stated she assessed Resident #1 as a full code and without a pulse and not breathing. LVN B stated she did not begin emergency CPR with chest compressions since Resident #1 was cool/cold, stiff and on his stomach. LVN B stated she thought RN G checked Resident #1's pulse. LVN B stated she attempted to roll Resident #1 over but was unsuccessful since it was difficult to push him, his arms were in the way. LVN B stated she did not ask for help in rolling over Resident #1. LVN B stated she did not ask for the crash cart, she did not get the AED machine since there was no time, she called 911 and that CPR was not an option since the resident was cold, stiff and on his stomach. LVN B stated 911 EMTs were at the bedside quickly approximately 2 minutes. LVN B stated when EMS arrived Resident #1 was assessed, and EMS did not start CPR and EMS left the facility. LVN B stated she knew Resident #1 was full code-which meant to try to revive a resident until EMS arrives. LVN B stated she was trained for CPR by the American Red Cross Association. LVN B stated her training included the use of an AED during CPR as soon as the AED was available. LVN B stated that prior to the incident around 4:30 AM she had last seen Resident #1 around 1:00 AM. Interview on [DATE] at 2:18 PM with CNA H revealed she worked on [DATE] from 10:00 PM to 6:00 AM. CNA H stated around 4:00 AM she went to check on Resident #1 and discovered Resident #1 on the floor in his room near the bathroom doorway with blood around him. CNA H immediately got help from LVN B. CNA H stated that when LVN B arrived to Resident #1's room LVN B touched Resident #1's hand for a pulse and immediately called 911. CNA H stated LVN B had instructed her to get help from RN G. CNA H stated that RN G did not assess or touch Resident #1. CNA H stated that RN G called the DON. CNA H stated that prior to the 4:00 AM incident she had last observed the Resident #1 around 1:30-2:00 AM. Interview and observation on [DATE] at 02:40 PM with the DON stated Resident #1 was discovered unresponsive and was not provided emergency CPR care. The DON stated she was certain the cart crash and AED was not used. The DON proceeded to demonstrate the AED to the surveyor. The AED was stored on the facility's emergency crash cart along with CPR equipment such as an oxygen tank, and oxygen delivery equipment and included a suction pump with accessories. The DON demonstrated the AED as functional and stated the AED had not been used and could not recall the last time it had been used. The DON stated that nothing had been used from the crash cart. The DON stated LVN B and RN G were directly involved with Resident #1's CPR care. Interview on [DATE] at 2:49 PM with MD A revealed he had been notified that Resident #1 had been found face down on the floor bleeding from the mouth and with no pulse. MD A stated he was told from LVN B's standpoint Resident #1 looked like he had been on the floor for some unknown period of time and LVN B called 911. MD A stated it was his expectation if a resident is full code and found unresponsive/without a pulse that CPR is started immediately including the use of the AED machine. Interview on [DATE] at 11:37 AM with the ADON revealed her expectation if a resident was discovered unresponsive and was full code that CPR was started immediately including obtaining the AED machine. The ADON stated that her expectation was for CPR to be started even if a resident's body was stiff. Interview on [DATE] at 10:16 AM with Agency (a company that provides a particular service) LVN I revealed she worked on [DATE] from 7:00 PM to 7:00 AM. Agency LVN I stated she was assigned to work Hall 200 on [DATE]. Agency LVN I stated she could not recall if a code blue (meaning unresponsive resident) was called during the shift. Agency LVN I stated she was providing patient care at an unknown time when a staff member (name unknown) stated they needed a nurse on the Hall 300. Agency LVN I stated when she arrived to Hall 300 Agency LVN she saw a resident (name unknown/room number unknown) on the floor in his room with blood around him. Agency LVN I stated that at the time she saw the resident (name unknown) on the floor LVN B and RN G were at the nursing station with the police, no one instructed her on anything so Agency LVN I stated she returned to Hall 200. Review of LVN B's employee's file revealed a certificate from the American Red Cross for completion of Adult and Pediatric CPR/AED on [DATE] with expiration date of two years . Review of LVN's Employee Disciplinary Record dated [DATE] revealed: Describe the action(s) that made it necessary to prepare this report. Include dates and any witnesses; LVN charge nurse failed to provide CPR to a full code resident once resident was found to be without vital signs. Type of Action: Suspension. Review of RN G's employee's file revealed a certificate from the American Heart Association for completion of Basic Life Support (CPR and AED) Program on [DATE] with expiration date of [DATE]. A record review of the facility's Emergency Procedure Cardiopulmonary Resuscitation policy dated [DATE], revealed, Policy Statement: personnel have completed training on the initiation of cardiopulmonary resuscitation and basic life support including defibrillation for victims of sudden cardiac arrest. General guidelines: .4. The chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. 5. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival .Emergency Procedure-Cardiopulmonary Resuscitation: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (Chest compressions, airway, breathing). 8. Continue with CPR/BLS until emergency medical personnel arrive . Review of the facility's Automatic External Defibrillator, Use and Care of, dated [DATE], revealed, Policy Interpretation and Implementation: The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected .remove the device from its case .check the battery cartridge to ensure it is in place .remove the film seals from the pads .turn on the device and follow the prompts . Review of the American Heart Association's website Part 3: Adult Basic and Advanced Life Support; 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support, accessed [DATE], revealed, Top 10 take home messages for adult cardiovascular life support: [ .] On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest [ .] Defibrillation is most successful when administered as soon as possible [ .]. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:58 PM. The facility ADM and DON were notified. The ADM was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 11:06 AM. Plan of Removal Undated 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]). Facility Medical Director was notified of the incident. ([DATE]) The DON or designee completed a chart audit on every resident and compared the advance directives to the physician order for accuracy. Inaccuracies were not identified. ([DATE]) Reviewed CPR policy and no update was needed. ([DATE]) The licensed nurse who did not perform CPR on the full code status resident was suspended pending investigation ([DATE]) 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion date: [DATE]) If a resident is full code, then CPR would be initiated according to policy. Disciplinary action was taken with licensed nurse who did not initiate CPR on the full code resident. The DON or designee educate all licensed nurses on the facility's policy and procedure for initiating CPR and location of code status for each resident. Licensed nurses were not permitted to work a shift until education was completed. Nurses on leave will receive education prior to their next scheduled shift. RN shift supervisor given new responsibility to direct/assign staff roles during code/initiation of code. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented, DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration on CPR process. Compliance checks will be conducted 2 times weekly for three months. Findings will be reported at monthly QAPI Committee meetings. DON or designee will audit new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit will continue daily for three months. Findings will be reviewed at the monthly QAPI Committee meetings. A Code Blue drill was performed with licensed nursing staff on all shifts until every nurse had participated at least once. Code Blue drills will continue to be held 2 times a month for 3 months. Findings will be reviewed at the monthly QAPI Committee meeting. Date Facility Asserts Likelihood for Serious Harm no Longer Exists: [DATE]. Plan Of Removal Verification Interview with MD A on [DATE] at 2:49 PM confirmed he was notified of the incident with Resident #1 on [DATE]. Interview with the DON on [DATE] at 6:00 AM revealed the facility DON/designee completed a 100% audit of residents' advanced directives. The audit was completed on [DATE]. No residents were identified to have improper advanced directives. Record review of the facility census revealed 22 residents requested they receive CPR (Cardiopulmonary Resuscitation) care and had full code orders signed by a physician. A record review of Resident #2's code status revealed Resident #2 was a full code. A record review of Resident #3's code status revealed Resident #3 was a full code. A record review of Resident #4's code status revealed Resident #4 was a full code. A record review of Resident #5's code status revealed Resident #5 was a full code. A record review of Resident #6's code status revealed Resident #6 was a full code. A record review of Resident #7's code status revealed Resident #7 was a full code. A record review of Resident #8's code status revealed Resident #8 was a full code. A record review of Resident #9's code status revealed Resident #9 was a full code. A record review of Resident #10's code status revealed Resident #10 was a full code. A record review of Resident #11's code status revealed Resident #11 was a full code. A record review of Resident #12's code status revealed Resident #12 was a full code. A record review of Resident #13's code status revealed Resident #13 was a full code. A record review of Resident #14's code status revealed Resident #14 was a full code. Disciplinary action was confirmed for LVN B on [DATE]. Review of Employee Disciplinary Record for LVN B revealed she was suspended on [DATE]. Review of in-service training on 03/27-[DATE] revealed the DON/designee initiated immediate competency-based training on the facility's policy and procedure for initiating CPR/location of crash cart, code blue, AED location/set up, emphasis on the expectation that the AED is retrieved immediately after checking for pulse and respirations, location of code status for each resident and documentation of CPR with nursing staff on all shifts on [DATE]. All education was at 100% completion as of [DATE]. Any nursing staff on leave will receive education prior to their next scheduled shift. Review of in-service training revealed the DON/designee initiated immediate training on the RN shift supervisor given the new responsibility to direct/assign shift roles during/initiation of code on both shifts on [DATE]. All education was at 100% completion as of [DATE]. Any RN on leave will receive education prior to their next scheduled shift. Review of in-service training revealed The DON/designee initiated immediate training on the facility's policy and procedure for identifying acute change in condition with all nursing staff on all shifts on [DATE]. All education was at 100% completion as of [DATE]. Any nursing staff on leave will receive education prior to their next scheduled shift. Review of facility's census for new admissions since [DATE] revealed one new admission on [DATE], Resident #15. A record review of Resident #15's code status revealed Resident #15 was a full code. Review of in-service revealed Nurse Manager/MDS Coordinator will in-service licensed nursing staff over Code Blue drill with return demonstration until every nurse had participated at least once. Monitoring will be conducted twice monthly for 3 months to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. The Director of Nursing/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training with nursing staff on all shifts on [DATE]. All education was at 100% completion as of [DATE]. Any nursing staff on leave will receive education prior to their next scheduled shift. Observation of a mock CPR AED event on [DATE] at 7:00 AM, revealed the LVN J called out that a resident was unresponsive. LVN J yelled out Code Blue from a resident's room. LVN J then delegated responsibilities to each staff, and instructed one staff to go get the crash cart. LVN J then proceeded to place a backboard under the mock resident while communicating out loud the importance of the backboard and if there was no backboard then to place the unresponsive resident on the floor. LVN J began compressions while counting out loud to 30, followed by using the AMBU (a type of device known as a bag valve mask, which is used to provide respiratory support) bag for the two breaths. The crash cart arrived during this time. The Nurse Manager/MDS Coordinator showed staff, while doing it, how to remove the AED from its case, opened the AED cover, which automatically began the verbal AED prompt protocols. The Nurse Manager/MDS Coordinator removed the AED pads from the case, attached the electrical pad leads to the AED, and placed the pads on the CPR mannequin, and continued to follow the AED verbal prompts. The Nurse Manager/MDS Coordinator stated to the mock CPR AED participants, Continue CPR with the AED until EMS arrives. (The following staff participated in the mock Code Blue: RN K, CNA L, RN M, CNA N, CNA O, MA P, RN Q, CNA R and LVN S) A record review of the facility's nursing roster revealed 24 nurses were employed by the facility over all 2 shifts of 7:00 AM-7:00 PM and 7:00 PM-7:00 AM. Nurses from both shifts were interviewed for participation in code blue training with return demonstration, CPR/AED training and were able to identify and use of AED with the emphasis on those that are full code and CPR documentation. Interview on [DATE] at 9:39 AM with CNA T she stated she worked the 2:00 PM-10:00 PM shift. CNA T stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 11:31 AM with LVN U she stated she worked the 7:00 PM-7:00 AM shift. LVN U stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 11:55 AM with CNA N she stated she worked the 6:00 AM-2:00 PM shift. CNA N stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 11:57 AM with CNA V she stated she worked the 2:00 PM-10:00 PM shift. CNA V stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:03 PM with CNA Z she stated she worked the 6:00 AM-2:00 PM shift. CNA stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:05 PM with CNA AA she stated she worked the 6:00 AM-2:00 PM and 2:00 PM-10:00 PM shift. CNA AA stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:09 PM with CNA BB she stated she worked the 6:00 AM-2:00 PM shift. CNA BB stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:11 PM with CNA O she stated she worked the 6:00 AM-2:00 PM shift. CNA O stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:16 PM with LVN W she stated she worked the 7:00 AM-7:00 PM shift. LVN W stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:28 PM with LVN X she stated she worked the 7:00 AM-7:00 PM shift. LVN X stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:43 PM with LVN Y she stated she worked the 7:00 AM-7:00 PM shift. LVN Y stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:53 PM with CNA CC she stated she worked the 6:00 AM-2:00 PM shift. CNA AA stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 1:12 PM with CNA DD she stated she worked the 10:00 PM-6:00 AM shift. CNA DD stated she had received training this week on code blue drill re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify and consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status for one (Resident #1) of one resident reviewed for notification of changes. The facility failed to ensure LVN B immediately notified the physician on 08/14/23 when Resident #1 had an elevated temperature of 100.3 F and N/V brownish partially digested food. The facility failed to ensure LVN A notified the physician on 08/15/23 that Resident #1's laboratory results were released to the facility on [DATE] at 12:55 PM. On 08/16/23 at 1:23 PM, the NP reviewed labs in PCC. Labs resulted WBC 22. UA with many bacteria, dehydration, and UTI. The facility failed to ensure LVN B immediately notified the physician on 08/17/23 at 1:10 AM there was a need to alter treatment significantly, decide to transfer, or discharge Resident #1 from the facility. On 08/17/23, after 5:00 PM, Resident #1 was sent to the ER. Resident #1 was admitted with a primary diagnosis of enterocolitis (inflammation in both intestines at once especially in a severe reaction to common infections) and severe sepsis (body's extreme reaction to an infection, can lead to organ failure, tissue damage and death) with acute kidney failure without septic shock. Additional diagnoses included acute cystitis (infection that only affects the bladder) without hematuria (blood in the urine); gastric outlet obstruction (a result of any disease process caused by mechanical and motility disorders associated with abdominal pain and postprandial vomiting); lung infiltrate (the presence of some unusual substance in the lungs); nausea and vomiting; and pyelonephritis (inflammation of the kidney, typically due to a bacterial infection). An Immediate Jeopardy (IJ) was identified on 10/02/23. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 10/04/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed residents at high risk of serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of Resident #1's admission Record, printed on 09/25/23, revealed the resident was a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated 07/12/23, revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician's orders reflected: - Order date 02/08/23: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: 09/08/23] - Order date 05/23/21: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date 08/14/23: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date 08/14/23: UA with C & S one time only r/o UTI. - Order date 08/15/23: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date 08/17/23: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until 08/17/23 11:59 PM. - Order date 08/17/23: Send to ER for further evaluation. A review of Resident #1's comprehensive care plan initiated 09/20/21 indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: 09/20/21; Revision on: 11/16/21] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. Review of Resident #1's progress notes indicated [last note prior to 08/14/23 was dated 8/10/23]: - Nurse's Note Effective Date: 08/14/23 at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 [degrees Fahrenheit] P92 R20 B/P 107/70. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: 08/14/23 at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis (action or process of vomiting) of undigested food and temp 100.4. Currently afebrile (not feverish). Positive for suprapubic (region of the abdomen located below the umbilical region) tenderness. Physical Examination 08/14/2023 (measured at 3:33 AM) BP: 103/60 HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed 8/10/23, pt was voiding around the catheter. Monitor wet diapers - Nurse's Note Effective Date: 08/14/23 at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP 113/60, P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. A record review of Resident #1's lab results report dated 08/15/23 revealed lab results collected on 08/15/23 at 9:35 AM and resulted in PCC (Resident #1 chart) on 08/15/23 at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on 10/10/23 at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes did not reflect any other progress notes until 08/16/23 at 1:18 PM. - Laboratory Results Note Effective Date: 08/16/23 at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician's Progress Note Effective Date: 08/16/23 at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on 08/16/2023 revealed: (at 3:52 PM) BP: 102/62 HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB. - Nurse's Note Effective Date: 08/17/23 at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P118/82 02sat 96%RA . (08/17/23) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place (08/17/23) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: 08/17/23 at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on 8/14/23 around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On 08/13/23 at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On 08/14/23 at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/14/23 at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On 08/15/23 at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On 08/15/23 at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On 08/16/23 at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On 08/16/23 at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On 08/17/23 at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/17/23 at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's August 2023 MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on 08/15/23 at 11:15 AM. Resident #1's August 2023 MAR reflected no other medications were administered to reduce an elevated temperature on 08/14/23 at 4:23 PM or as documented in nurse's progress notes: On 08/14/23 at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On 08/14/23 at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated 08/17/23 reflected Resident #1 arrived at the ER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: 99/66; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member Resident #1 was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of the ER triage notes of an initial evaluation by a qualified medical provider focused examination dated 08/17/23 at 5:42 PM indicated Resident #1 appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on 08/17/23 at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of Resident #1's blood labs collected in the ER on [DATE] at 5:53 PM resulted 08/17/23 at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on 10/10/23 at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated 08/17/23 at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . Resident #1 was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of 08/18/23 at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis, acute renal failure, and atrial flutter. During an interview on 09/20/23 at 10:38 AM, LVN F said he was familiar with Resident #1's care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, a family member was at bedside daily and assisted with care. LVN F defined a change in condition as a change in functioning such as a verbal decline, fever, not eating . anything out of the ordinary from the resident baseline. LVN F said that he would assess the resident that experienced a change in condition and notify the MD using the SBAR technique (a framework for communication between members of the health care team about a patient's condition). LVN F said that a resident who was unable to communicate verbally could be assessed by visual inspection of non-verbal signs such as grunts, moans, guarding, and behaviors that suggest distress. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, and dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, and decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuated outside of the MD's acceptable parameters. LVN F said if a resident had a temperature of 99 degrees (Fahrenheit) or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, and then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when he was last assigned to Resident #1 on 09/09/23. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of 08/13/23 and was surprised when he returned from vacation that Resident #1 was sent to the hospital. During an interview on 09/20/23 at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident's catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses inform her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on 08/10/23 to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on 08/14/23 around 7:00 AM, she received a snapshot of a progress note from LVN B (worked 08/13/23 7P - 7A shift) via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning (08/14/23) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had an UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for a higher level of care on 08/17/23. During an interview on 09/25/23 at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room (08/17/23) when Resident #1 was sent out to hospital. Resident #1 did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on 09/25/23 at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before being sent to the hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident's clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative were examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize a change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever (could not state a specific date and time, referred to the week of 08/13/23 - 08/17/23) that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON stated nurses should document when the nurse reviewed lab results, notified the MD, and if orders were received. The DON indicated when the MD wrote orders for labs, the primary nurse completed a lab request. The DON said her expectations were for the nurse to review and notify the MD as soon as lab results were received and if any new orders were received, they should be carried out and documented. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI (before transferred to hospital). The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on 09/25/23 at 1:37 PM, a family member stated concerns started on 08/10/23 when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in January 2021 with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on 08/13/23. The family member stated the fever continued until 08/15/23, which at that time, Resident #1 had a low-grade fever of 99.8 degrees (Fahrenheit). The family member said that they were notified on 08/16/23 that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and (family member) wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, her heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on 8/18/2023, that nothing could be done, and the resident would benefit from palliative care. On 08/24/23, Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on 8/26/2023. The family member said that Resident #1 passed away because of the sepsis. During an interview on 09/25/23 at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when they provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident, not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine the cause of the change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about the resident's clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1, that she appeared lethargic (lack of energy), didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on 10/02/23 at 12:41 PM, LVN A said that she was familiar with Resident #1 and her care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any were given. LVN A said signs of an UTI were strong smelling urine, urine that looked cloudy, a fever, and the resident may become confused. LVN A said that she worked on 08/14/23 and was informed in report that Resident #1's fc was removed because it kept leaking. LVN A said that the reporting nurse [LVN B] said that Resident #1 threw up overnight once and had a fever. LVN A said that the NP saw Resident #1 in the early afternoon (08/14/23) and wrote orders for labs and an UA with C & S. LVN A said that she collected the urine specimen and called the lab company to schedule the lab draw and pick up the urine specimen. LVN A said that when she collected Resident #1's urine specimen, the urine had a foul smell. LVN A said that the procedure for lab tests is to enter the order, complete a requisition, and call the laboratory to schedule. LVN A said that the nurse checked the resident chart for the lab results. If the lab results were not reported by the end of their shift, the nurse should give report to the oncoming nurse to check for lab results. Once the lab results are received, electronically sent directly to the resident chart by the lab, the nurse will review and immediately notify the MD that the results are ready for review or inform of any abnormal/critical lab results. LVN A said the MD is notified via the messaging app or if critical lab results, the nurse must call the MD, and document notification/communication with the provider. LVN A said that she was not assigned to Resident #1 the next day (08/15/23) when the labs were scheduled to be drawn and results expected to return. Resident #1's vital signs were reviewed with LVN A and attention directed to the temperature summary that reflected an elevated temperature entered by LVN A and the MAR revealed LVN A administered acetaminophen to Resident #1 on 08/15/23. LVN A stated that she did not recall working on that day and if she worked, she would have checked for the lab results and notified the MD. During a follow up interview on 10/02/23 at 1:27 PM, LVN A said that she checked with the staffing coordinator and verified she worked on 08/15/23 and was assigned to Resident #1. LVN A said that she did know how Resident #1's labs were missed and not reviewed. LVN A said that the risk to a resident if labs were not reviewed in a timely manner would be in a delay in treatment and worsening of an infection. During an interview on 10/02/23 at 7:06 PM, LVN B said that she worked the evening shift, 7P - 7A and was familiar with Resident #1 and her care needs as the primary assigned nurse. LVN B said that Resident #1 was totally dependent for ADLs, confused, could respond to questions with a head nod/shake or answer yes or no, and had a FC that was removed. The FC was scheduled to be changed every 3 weeks or PRN. LVN B said that the CNA was responsible for providing catheter care during incontinent care. The task was on the MAR, and the nurse had to sign off nightly that the CNA performed catheter care using baby shampoo. LVN B said that she assisted the CNA with catheter care nightly, so she would assess if there was any[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 1 resident (Resident #1) reviewed for neglect. The facility failed to ensure LVN A and LVN B did not neglect Resident #1. They failed to implement nursing interventions as written in Resident #1's care plan. LVN B failed to immediately contact the physician when Resident #1 had an acute change in condition. LVN A failed to immediately contact the physician of abnormal labs results, which indicated infection and dehydration, when received. These cumulative failures caused a delay in medical treatment to Resident #1, who was then hospitalized with diagnoses of enterocolitis (inflammation in both intestines at once especially in a severe reaction to common infections) and severe sepsis (body's extreme reaction to an infection, can lead to organ failure, tissue damage and death) with acute kidney failure. An Immediate Jeopardy (IJ) was identified on 10/02/23. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was lowered on 10/04/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed residents at high risk of serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of the facility's Risk management: Abuse, Neglect, Exploitation, Mistreatment of Resident, or Misappropriation of Resident Property policy, Effective Date: January 2012, Change date(s): November 2016, revealed: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Neglect - Failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure 4. The NFA, DON and Risk manager are also ultimately responsible for the following: Implementation, ongoing monitoring, reporting, investigation, tracking and trending. 5. Implementation and ongoing monitoring consist of the following: Screening, training, prevention, Screening Potential employees will be screened during the hiring process for history of abuse, neglect, or mistreatment of residents. Training Facility orientation program & ongoing training programs will include, but may not be limited to Freedom from ANE requirements. Prevention: Post a statement that the resident may file a complaint with eh State Survey Agency . Post information & contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect . Investigation An Event Report is initiated. Reporting The facility will identify the staff member responsible for the initial reporting, investigation of alleged violations & reporting abuse, & to determine the direction of the investigation. DCF, HHS, Law Enforcement will be notified immediately via telephone or fax. Record review of Resident #1's admission Record, printed on 09/25/23, revealed a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated 07/12/23, revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician orders reflected: - Order date 02/08/23: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: 09/08/23] - Order date 04/25/23: Monitor indwelling catheter for blockage, leakage, sediment, buildup, output, urine color and odor every shift for retention. - Order date 05/23/21: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date 05/28/23: Nurse is to ensure CNA provide catheter care with baby shampoo and warm water, rinsing and patting dry every shift. This includes cleaning inner labia. - Order date 06/11/23: Irrigate foley with NS every shift for control of sediment - Order date 08/10/23: Discontinue foley (indwelling catheter) one time only for bladder spasms - Order date 08/10/23: Trospium Chloride Oral tablet 20 mg. Give 1 tablet by mouth two times a day for bladder spasms - Order date 08/10/23: Monitor output every shift d/t discontinuation of f/c - Order date 08/14/23: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date 08/14/23: UA with C & S one time only r/o UTI. - Order date 08/15/23: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date 08/16/23: May insert Midline IV (a long, thin, flexible tube inserted into a large vein in the upper arm used to administer medication into the bloodstream) for infusion - Order date 08/16/23: Sodium Chloride Soln 0.9%. Use 100 mL/hr IV every shift for hydration for 3 days. (Give 2 liters of NS 0.9% via midline) - Order date 08/17/23: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until 08/17/23 11:59 PM. - Order date 08/17/23: Merrem (antibiotic) IV soln 500 mg. Use 500 mg IV two times a day for UTI for 7 days. - Order date 08/17/23: Ceftriaxone (antibiotic) 1 GM injection solution. Inject 1 gram intramuscularly STAT for UTI. - Order date 08/17/23: Send to ER for further evaluation. A review of Resident #1's comprehensive care plan initiated 09/20/21 indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: 09/20/21; Revision on: 11/16/21] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. Review of Resident #1's progress notes indicated [last note prior to 08/14/23 was dated 8/10/23]: - Nurse's Note Effective Date: 08/14/23 at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 [degrees Fahrenheit] P92 R20 B/P 107/70. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: 08/14/23 at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis (action or process of vomiting) of undigested food and temp 100.4. Currently afebrile (not feverish). Positive for suprapubic (region of the abdomen located below the umbilical region) tenderness. Physical Examination 08/14/2023 (measured at 3:33 AM) BP: 103/60 HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed 8/10/23, pt was voiding around the catheter. Monitor wet diapers - Nurse's Note Effective Date: 08/14/23 at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP 113/60, P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. A record review of Resident #1's lab results report dated 08/15/23 revealed lab results collected on 08/15/23 at 9:35 AM and resulted in PCC (Resident #1 chart) on 08/15/23 at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on 10/10/23 at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes did not reflect any other progress notes until 08/16/23 at 1:18 PM. - Laboratory Results Note Effective Date: 08/16/23 at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician's Progress Note Effective Date: 08/16/23 at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on 08/16/2023 revealed: (at 3:52 PM) BP: 102/62 HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB. - Nurse's Note Effective Date: 08/17/23 at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P118/82 02sat 96%RA . (08/17/23) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place (08/17/23) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: 08/17/23 at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on 8/14/23 around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On 08/13/23 at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On 08/14/23 at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/14/23 at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On 08/15/23 at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On 08/15/23 at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On 08/16/23 at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On 08/16/23 at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On 08/17/23 at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/17/23 at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's August 2023 MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on 08/15/23 at 11:15 AM. Resident #1's August 2023 MAR reflected no other medications were administered to reduce an elevated temperature on 08/14/23 at 4:23 PM or as documented in nurse's progress notes: On 08/14/23 at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On 08/14/23 at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated 08/17/23 reflected Resident #1 arrived at the ER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: 99/66; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member Resident #1 was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of the ER triage notes of an initial evaluation by a qualified medical provider focused examination dated 08/17/23 at 5:42 PM indicated Resident #1 appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on 08/17/23 at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of Resident #1's blood labs collected in the ER on [DATE] at 5:53 PM resulted 08/17/23 at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on 10/10/23 at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated 08/17/23 at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . Resident #1 was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of 08/18/23 at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis, acute renal failure, and atrial flutter. During an interview on 09/20/23 at 10:38 AM, LVN F said he was familiar with Resident #1's care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, a family member was at bedside daily and assisted with care. LVN F defined a change in condition as a change in functioning such as a verbal decline, fever, not eating . anything out of the ordinary from the resident baseline. LVN F said that he would assess the resident that experienced a change in condition and notify the MD using the SBAR technique (a framework for communication between members of the health care team about a patient's condition). LVN F said that a resident who was unable to communicate verbally could be assessed by visual inspection of non-verbal signs such as grunts, moans, guarding, and behaviors that suggest distress. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, and dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, and decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuated outside of the MD's acceptable parameters. LVN F said if a resident had a temperature of 99 degrees (Fahrenheit) or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, and then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when he was last assigned to Resident #1 on 09/09/23. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of 08/13/23 and was surprised when he returned from vacation that Resident #1 was sent to the hospital. During an interview on 09/20/23 at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident's catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses inform her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on 08/10/23 to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on 08/14/23 around 7:00 AM, she received a snapshot of a progress note from LVN B (worked 08/13/23 7P - 7A shift) via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning (08/14/23) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had an UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for a higher level of care on 08/17/23. During an interview on 09/25/23 at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room (08/17/23) when Resident #1 was sent out to hospital. Resident #1 did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on 09/25/23 at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before being sent to the hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident's clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative were examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize a change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever (could not state a specific date and time, referred to the week of 08/13/23 - 08/17/23) that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON stated nurses should document when the nurse reviewed lab results, notified the MD, and if orders were received. The DON indicated when the MD wrote orders for labs, the primary nurse completed a lab request. The DON said her expectations were for the nurse to review and notify the MD as soon as lab results were received and if any new orders were received, they should be carried out and documented. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI (before transferred to hospital). The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on 09/25/23 at 1:37 PM, a family member stated concerns started on 08/10/23 when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in January 2021 with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on 08/13/23. The family member stated the fever continued until 08/15/23, which at that time, Resident #1 had a low-grade fever of 99.8 degrees (Fahrenheit). The family member said that they were notified on 08/16/23 that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and (family member) wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, her heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on 8/18/2023, that nothing could be done, and the resident would benefit from palliative care. On 08/24/23, Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on 8/26/2023. The family member said that Resident #1 passed away because of the sepsis. During an interview on 09/25/23 at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when they provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident, not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine the cause of the change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about the resident's clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1, that she appeared lethargic (lack of energy), didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on 10/02/23 at 12:41 PM, LVN A said that she was familiar with Resident #1 and her care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any were given. LVN A said signs of an UTI were strong smelling urine, urine t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for 1 of 1 resident (Resident #1) reviewed for provision of care and services by staff. The facility failed to oversee the implementation of required structures and processes to meet the needs of Resident #1. The facility failed to oversee LVN A and LVN B followed resident care policies and procedures during the provision of care and services to Resident #1. The facility failed to conduct ongoing monitoring and supervision of LVN A and LVN B to assure the implementation of Resident #1's care plan as written. The facility failed to ensure there was an effective communication system across all shifts for communicating necessary care and information between staff, practitioner, and resident representatives. An Immediate Jeopardy (IJ) was identified on 10/02/23. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was lowered on 10/04/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed residents at high risk of serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of the facility's Risk management: Abuse, Neglect, Exploitation, Mistreatment of Resident, or Misappropriation of Resident Property policy, Effective Date: January 2012, Change date(s): November 2016, revealed: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Neglect - Failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure 4. The NFA, DON and Risk manager are also ultimately responsible for the following: Implementation, ongoing monitoring, reporting, investigation, tracking and trending. 5. Implementation and ongoing monitoring consist of the following: Screening, training, prevention, Screening Potential employees will be screened during the hiring process for history of abuse, neglect, or mistreatment of residents. Training Facility orientation program & ongoing training programs will include, but may not be limited to Freedom from ANE requirements. Prevention: Post a statement that the resident may file a complaint with eh State Survey Agency . Post information & contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect . Investigation An Event Report is initiated. Reporting The facility will identify the staff member responsible for the initial reporting, investigation of alleged violations & reporting abuse, & to determine the direction of the investigation. DCF, HHS, Law Enforcement will be notified immediately via telephone or fax. Record review of Resident #1's admission Record, printed on 09/25/23, revealed a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated 07/12/23, revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician's orders reflected: - Order date 02/08/23: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: 09/08/23] - Order date 05/23/21: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date 08/10/23: Monitor output every shift d/t discontinuation of f/c - Order date 08/14/23: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date 08/14/23: UA with C & S one time only r/o UTI. - Order date 08/15/23: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date 08/17/23: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until 08/17/23 11:59 PM. - Order date 08/17/23: Send to ER for further evaluation. A review of Resident #1's comprehensive care plan initiated 09/20/21 indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: 09/20/21; Revision on: 11/16/21] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. Review of Resident #1's progress notes indicated [last note prior to 08/14/23 was dated 8/10/23]: - Nurse's Note Effective Date: 08/14/23 at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 [degrees Fahrenheit] P92 R20 B/P 107/70. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: 08/14/23 at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis (action or process of vomiting) of undigested food and temp 100.4. Currently afebrile (not feverish). Positive for suprapubic (region of the abdomen located below the umbilical region) tenderness. Physical Examination 08/14/2023 (measured at 3:33 AM) BP: 103/60 HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed 8/10/23, pt was voiding around the catheter. Monitor wet diapers - Nurse's Note Effective Date: 08/14/23 at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP 113/60, P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. A record review of Resident #1's lab results report dated 08/15/23 revealed lab results collected on 08/15/23 at 9:35 AM and resulted in PCC (Resident #1 chart) on 08/15/23 at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on 10/10/23 at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes did not reflect any other progress notes until 08/16/23 at 1:18 PM. - Laboratory Results Note Effective Date: 08/16/23 at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician's Progress Note Effective Date: 08/16/23 at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on 08/16/2023 revealed: (at 3:52 PM) BP: 102/62 HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB. - Nurse's Note Effective Date: 08/17/23 at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P118/82 02sat 96%RA . (08/17/23) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place (08/17/23) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: 08/17/23 at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on 8/14/23 around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On 08/13/23 at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On 08/14/23 at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/14/23 at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On 08/15/23 at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On 08/15/23 at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On 08/16/23 at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On 08/16/23 at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On 08/17/23 at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/17/23 at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's August 2023 MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on 08/15/23 at 11:15 AM. Resident #1's August 2023 MAR reflected no other medications were administered to reduce an elevated temperature on 08/14/23 at 4:23 PM or as documented in nurse's progress notes: On 08/14/23 at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On 08/14/23 at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated 08/17/23 reflected Resident #1 arrived at the ER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: 99/66; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member Resident #1 was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of the ER triage notes of an initial evaluation by a qualified medical provider focused examination dated 08/17/23 at 5:42 PM indicated Resident #1 appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on 08/17/23 at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of Resident #1's blood labs collected in the ER on [DATE] at 5:53 PM resulted 08/17/23 at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on 10/10/23 at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated 08/17/23 at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . Resident #1 was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of 08/18/23 at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis, acute renal failure, and atrial flutter. During an interview on 09/20/23 at 10:38 AM, LVN F said he was familiar with Resident #1's care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, a family member was at bedside daily and assisted with care. LVN F defined a change in condition as a change in functioning such as a verbal decline, fever, not eating . anything out of the ordinary from the resident baseline. LVN F said that he would assess the resident that experienced a change in condition and notify the MD using the SBAR technique (a framework for communication between members of the health care team about a patient's condition). LVN F said that a resident who was unable to communicate verbally could be assessed by visual inspection of non-verbal signs such as grunts, moans, guarding, and behaviors that suggest distress. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, and dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, and decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuated outside of the MD's acceptable parameters. LVN F said if a resident had a temperature of 99 degrees (Fahrenheit) or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, and then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when he was last assigned to Resident #1 on 09/09/23. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of 08/13/23 and was surprised when he returned from vacation that Resident #1 was sent to the hospital. During an interview on 09/20/23 at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident's catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses inform her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on 08/10/23 to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on 08/14/23 around 7:00 AM, she received a snapshot of a progress note from LVN B (worked 08/13/23 7P - 7A shift) via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning (08/14/23) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had an UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for a higher level of care on 08/17/23. During an interview on 09/25/23 at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room (08/17/23) when Resident #1 was sent out to hospital. Resident #1 did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on 09/25/23 at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before being sent to the hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident's clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative were examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize a change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever (could not state a specific date and time, referred to the week of 08/13/23 - 08/17/23) that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON stated nurses should document when the nurse reviewed lab results, notified the MD, and if orders were received. The DON indicated when the MD wrote orders for labs, the primary nurse completed a lab request. The DON said her expectations were for the nurse to review and notify the MD as soon as lab results were received and if any new orders were received, they should be carried out and documented. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI (before transferred to hospital). The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on 09/25/23 at 1:37 PM, a family member stated concerns started on 08/10/23 when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in January 2021 with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on 08/13/23. The family member stated the fever continued until 08/15/23, which at that time, Resident #1 had a low-grade fever of 99.8 degrees (Fahrenheit). The family member said that they were notified on 08/16/23 that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and (family member) wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, her heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on 8/18/2023, that nothing could be done, and the resident would benefit from palliative care. On 08/24/23, Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on 8/26/2023. The family member said that Resident #1 passed away because of the sepsis. During an interview on 09/25/23 at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when they provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident, not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine the cause of the change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about the resident's clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1, that she appeared lethargic (lack of energy), didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on 10/02/23 at 12:41 PM, LVN A said that she was familiar with Resident #1 and her care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any were given. LVN A said signs of an UTI were strong smelling urine, urine that looked cloudy, a fever, and the resident may become confused. LVN A said that she worked on 08/14/23 and was informed in report that Resident #1's fc was removed because it kept leaking. LVN A said that the reporting nurse [LVN B] said that Resident #1 threw up overnight once and had a fever. LVN A said that the NP saw Resident #1 in the early afternoon (08/14/23) and wrote orders for labs and an UA with C & S. LVN A said that she collected the urine specimen and called the lab company to schedule the lab draw and pick up the urine specimen. LVN A said that when she collected Resident #1's urine specimen, the urine had a foul smell. LVN A said that the procedure for lab tests is to enter the order, complete a requisition, and call the laboratory to schedule. LVN A said that the nurse checked the resident chart for the lab results. If the lab results were not reported by the end of their shift, the nurse should give report to the oncoming nurse to check for lab results. Once the lab results are received, electronically sent directly to the resident chart by the lab, the nurse will review and immediately notify the MD that the results are ready for review or inform of any abnormal/critical lab results. LVN A said the MD is notified via the messaging app or if critical lab results, the nurse must call the MD, and document notification/communication with the provider. LVN A said that she was not assigned to Resident #1 the next day (08/15/23) when the labs were scheduled to be drawn and results expected to return. Resident #1's vital signs were reviewed with LVN A and attention directed to the temperature summary that reflect[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one (Resident #1) of five residents reviewed for Urinary Tract Infection (UTI). On 08/10/23 Resident #1's FC was discontinued after unknown nurse reported leakage. The facility failed to ensure LVN B immediately notified the physician on 08/14/23 when Resident #1 had an elevated temperature of 100.3 F and N/V brownish partially digested food. The facility failed to ensure LVN A notified the physician on 08/15/23 that Resident #1's laboratory results were released to the facility on [DATE] at 12:55 PM. On 08/16/23 at 1:23 PM, the NP reviewed labs in PCC. Labs resulted WBC 22. UA with many bacteria, dehydration, and UTI. The facility failed to ensure LVN B immediately notified the physician on 08/17/23 at 1:10 AM there was a need to alter treatment significantly, decide to transfer, or discharge Resident #1 from the facility when Resident #1 had a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor . On 08/17/23, after 5:00 PM, Resident #1 was sent to the ER. Resident #1 was admitted with a primary diagnosis of Enterocolitis (inflammation in both intestines at once especially in a severe reaction to common infections) and Severe sepsis with acute renal failure without septic shock. Additional diagnoses included acute cystitis (infection that only affects the bladder) without hematuria (blood in the urine) An Immediate Jeopardy (IJ) was identified on 10/02/23. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 10/04/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This failure placed residents at high risk of serious injury, harm, impairment, or death by not receiving treatment, developing complications such as injury to the urinary tract, and the development of sepsis. Findings included: Record review of Resident #1's admission Record, printed on 09/25/23, revealed a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated 07/12/23, revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician orders reflected: - Order date 02/08/23: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: 09/08/23] - Order date 04/25/23: Monitor indwelling catheter for blockage, leakage, sediment, buildup, output, urine color and odor every shift for retention. - Order date 05/23/21: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date 05/28/23: Nurse is to ensure CNA provide catheter care with baby shampoo and warm water, rinsing and patting dry every shift. This includes cleaning inner labia. - Order date 06/11/23: Irrigate foley with NS every shift for control of sediment - Order date 08/10/23: Discontinue foley (indwelling catheter) one time only for bladder spasms - Order date 08/10/23: Trospium Chloride Oral tablet 20 mg. Give 1 tablet by mouth two times a day for bladder spasms - Order date 08/10/23: Monitor output every shift d/t discontinuation of f/c - Order date 08/14/23: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date 08/14/23: UA with C & S one time only r/o UTI. - Order date 08/15/23: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date 08/16/23: May insert Midline IV (a long, thin, flexible tube inserted into a large vein in the upper arm used to administer medication into the bloodstream) for infusion - Order date 08/16/23: Sodium Chloride Soln 0.9%. Use 100 mL/hr IV every shift for hydration for 3 days. (Give 2 liters of NS 0.9% via midline) - Order date 08/17/23: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until 08/17/23 11:59 PM. - Order date 08/17/23: Merrem (antibiotic) IV soln 500 mg. Use 500 mg IV two times a day for UTI for 7 days. - Order date 08/17/23: Ceftriaxone (antibiotic) 1 GM injection solution. Inject 1 gram intramuscularly STAT for UTI. - Order date 08/17/23: Send to ER for further evaluation. A review of Resident #1's comprehensive care plan initiated 09/20/21 indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: 09/20/21; Revision on: 11/16/21] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. A record review of Resident #1's lab results report dated 08/15/23 revealed lab results collected on 08/15/23 at 9:35 AM and reported on 08/15/23 at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on 10/10/23 at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes indicated: - Nurse's Note Effective Date: 08/14/23 at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 P92 R20 B/P 107/70. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: 08/14/23 at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis of undigested food and temp 100.4. Currently afebrile. Positive for suprapubic tenderness. Physical Examination 08/14/2023 (measured at 3:33 AM) BP: 103/60 HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed 8/10/23, pt was voiding around the catheter. Monitor wet diapers . - Nurse's Note Effective Date: 08/14/23 at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP 113/60, P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. Review of Resident #1's progress notes did not reflect any other progress notes until 08/16/23 at 1:18 PM. - Laboratory Results Note Effective Date: 08/16/23 at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician Progress Note Effective Date: 08/16/23 at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on 08/16/2023 revealed: (at 3:52 PM) BP: 102/62 HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB - Nurse's Note Effective Date: 08/17/23 at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P118/82 02sat 96%RA . (08/17/23) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place (08/17/23) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: 08/17/23 at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on 8/14/23 around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On 08/13/23 at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On 08/14/23 at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/14/23 at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On 08/15/23 at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On 08/15/23 at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On 08/16/23 at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On 08/16/23 at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On 08/17/23 at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/17/23 at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's August 2023 MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on 08/15/23 at 11:15 AM. Resident #1's August 2023 MAR reflected no other medications were administered to reduce an elevated temperature on 08/14/23 at 4:23 PM or as documented in nurse's progress notes: On 08/14/23 at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On 08/14/23 at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated 08/17/23 reflected [Resident #1] arrived at the ER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: 99/66; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member [Resident #1] was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of ER triage notes of an initial evaluation by a qualified medical provider focused examination dated 08/17/23 at 5:42 PM indicated [Resident #1] appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on 08/17/23 at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of blood labs collected in the ER on [DATE] at 5:53 PM resulted 08/17/23 at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on 10/10/23 at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated 08/17/23 at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . [Resident #1] was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of 08/18/23 at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis (a bacterial infection causing inflammation of the kidneys), acute renal failure, and atrial flutter. During an interview on 09/20/23 at 10:38 AM, LVN F said he was familiar with Resident #1 care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, family member was at bedside daily and assisted with care. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuate outside of MD acceptable parameters. LVN F said if a resident had a temperature of 99 degrees or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when last assigned to Resident #1 on 10/09/23. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of 08/13/23 and was surprised when returned from vacation that Resident #1 was sent to the hospital. During an interview on 09/20/23 at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that on or about 08/10/2023, she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses informed her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on 08/10/23 to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on 08/14/23 around 7:00 AM, she received a snapshot of a progress note from LVN B via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning (08/14/23) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had a UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for higher level of care on 08/17/23. During an interview on 09/25/23 at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room (08/17/23) when Resident #1 was sent out to hospital. Resident did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on 09/25/23 at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before sent to hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative as examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident condition to be able to recognize change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI. The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on 09/25/23 at 1:37 PM, a family member stated concerns started on 08/10/23 when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in January 2021 with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on 08/13/23. The family member stated the fever continued until 08/15/23, which at that time, Resident #1 had a low-grade fever of 99.8 degrees. The family member said that they were notified on 08/16/23 that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on 8/18/2023, that nothing could be done, and the resident would benefit from palliative care. On 08/24/23, Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on 8/26/2023. The family member said that Resident #1 passed away because of the sepsis. During an interview on 09/25/23 at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident - not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine cause of change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about resident clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1 that appeared lethargic, didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on 10/02/23 at 12:41 PM, LVN A said that she was familiar with Resident #1 and their care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any given. LVN A said signs of an UTI were strong-smelling urine, urine that looked cloudy, fever, and the resident may become confused. LVN A said that she worked on 08/14/23 and was informed in report that Resident #1's fc was removed because it kept leaking. LVN A said that the reporting nurse said that Resident #1 threw up overnight once and had a fever. LVN A said that the NP saw Resident #1 in the early afternoon (08/14/23) and wrote orders for labs and an UA with C & S. LVN A said that she collected the urine specimen and called the lab company to schedule the lab draw and pick up the urine specimen. LVN A said that when she collected Resident #1's urine specimen, the urine had a foul smell. During an interview on 10/02/23 at 7:06 PM, LVN B said that she worked the evening shift, 7P - 7A and was familiar with Resident #1 and their care needs as the primary assigned nurse. LVN B said that Resident #1 was total dependent for ADLs, confused, could respond to questions with a head nod/shake or answer Yes or No, and had a FC that was removed. The FC was scheduled to be changed every 3 weeks or PRN. LVN B said that the CNA was responsible for providing catheter care during incontinent care. The task was on the MAR, and the nurse had to sign off nightly that the CNA performed catheter care using baby shampoo. LVN B said that she assisted the CNA with catheter care nightly, so she would assess if there was any trauma, signs, or symptoms of infection. LVN B said she gently tugged on the catheter tubing at the insert site to check for placement and checked if the balloon was inflated. LVN B said there was an order to encourage Resident #1 to drink fluids because she did not drink enough water, and there was sedimentation often noted in the urine. LVN B said that she flushed Resident #1 FC every night with 60 cc NS and monitored urine output per orders to prevent catheter complications. LVN B said the risk of not flushing the catheter would cause problems such as, catheter leakage, blocked catheter, catheter coming out, or an infection. LVN B said s/sx of an UTI included fever, sleepiness, decreased urine output, dark, foul smelling urine. In a continued interview on 10/02/23 at 7:06 PM, LVN B said that she worked 08/15/23 and 08/16/23, 7P - 7A. LVN B said she did not recall if Resident #1 had a fever but did perform an in/out (straight) cath one night after the MD was called and received an order. LVN B said the order was to leave the fc in place if the urine output was 250cc or more. LVN B said that there was 200cc reddish brown urine output and did not leave the catheter in place. LVN B indicated she wrote the progress note that described the urine output as reddish-brown, foul smelling, and with white sediment. LVN B denied she notified the MD of the urine characteristics because that was common for Resident #1. LVN B restated s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges for one (Resident #1) of five residents reviewed for Laboratory Services. The facility failed to ensure LVN A notified the physician on 08/15/23 that Resident #1's laboratory results were released to the facility on [DATE] at 12:55 PM. On 08/16/23 at 1:23 PM, the NP reviewed labs in PCC. Labs resulted WBC 22. UA with many bacteria, dehydration, and UTI. An Immediate Jeopardy (IJ) was identified on 10/02/23. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 10/04/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice place residents at risk of not receiving treatment, developing sepsis, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of Resident #1's admission Record, printed on 09/25/23, revealed the resident was a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated 07/12/23, revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician's orders reflected: - Order date 02/08/23: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: 09/08/23] - Order date 05/23/21: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date 08/14/23: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date 08/14/23: UA with C & S one time only r/o UTI. - Order date 08/15/23: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date 08/17/23: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until 08/17/23 11:59 PM. - Order date 08/17/23: Send to ER for further evaluation. Review of Resident #1's progress notes indicated [last note prior to 08/14/23 was dated 8/10/23]: - Nurse's Note Effective Date: 08/14/23 at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 [degrees Fahrenheit] P92 R20 B/P 107/70. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: 08/14/23 at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis (action or process of vomiting) of undigested food and temp 100.4. Currently afebrile (not feverish). Positive for suprapubic (region of the abdomen located below the umbilical region) tenderness. Physical Examination 08/14/2023 (measured at 3:33 AM) BP: 103/60 HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed 8/10/23, pt was voiding around the catheter. Monitor wet diapers - Nurse's Note Effective Date: 08/14/23 at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP 113/60, P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. A review of Resident #1's comprehensive care plan initiated 09/20/21 indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: 09/20/21; Revision on: 11/16/21] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. A record review of Resident #1's lab results report dated 08/15/23 revealed lab results collected on 08/15/23 at 9:35 AM and resulted in PCC (Resident #1 chart) on 08/15/23 at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on 10/10/23 at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes did not reflect any other progress notes until 08/16/23 at 1:18 PM. - Laboratory Results Note Effective Date: 08/16/23 at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician's Progress Note Effective Date: 08/16/23 at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on 08/16/2023 revealed: (at 3:52 PM) BP: 102/62 HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB. - Nurse's Note Effective Date: 08/17/23 at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P118/82 02sat 96%RA . (08/17/23) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place (08/17/23) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: 08/17/23 at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on 8/14/23 around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On 08/13/23 at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On 08/14/23 at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/14/23 at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On 08/15/23 at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On 08/15/23 at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On 08/16/23 at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On 08/16/23 at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On 08/17/23 at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On 08/17/23 at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's August 2023 MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on 08/15/23 at 11:15 AM. Resident #1's August 2023 MAR reflected no other medications were administered to reduce an elevated temperature on 08/14/23 at 4:23 PM or as documented in nurse's progress notes: On 08/14/23 at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On 08/14/23 at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated 08/17/23 reflected Resident #1 arrived at the ER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: 99/66; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member Resident #1 was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of the ER triage notes of an initial evaluation by a qualified medical provider focused examination dated 08/17/23 at 5:42 PM indicated Resident #1 appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on 08/17/23 at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of Resident #1's blood labs collected in the ER on [DATE] at 5:53 PM resulted 08/17/23 at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on 10/10/23 at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated 08/17/23 at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . Resident #1 was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of 08/18/23 at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis, acute renal failure, and atrial flutter. During an interview on 09/20/23 at 10:38 AM, LVN F said he was familiar with Resident #1's care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, a family member was at bedside daily and assisted with care. LVN F defined a change in condition as a change in functioning such as a verbal decline, fever, not eating . anything out of the ordinary from the resident baseline. LVN F said that he would assess the resident that experienced a change in condition and notify the MD using the SBAR technique (a framework for communication between members of the health care team about a patient's condition). LVN F said that a resident who was unable to communicate verbally could be assessed by visual inspection of non-verbal signs such as grunts, moans, guarding, and behaviors that suggest distress. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, and dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, and decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuated outside of the MD's acceptable parameters. LVN F said if a resident had a temperature of 99 degrees (Fahrenheit) or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, and then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when he was last assigned to Resident #1 on 09/09/23. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of 08/13/23 and was surprised when he returned from vacation that Resident #1 was sent to the hospital. During an interview on 09/20/23 at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident's catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses inform her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on 08/10/23 to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on 08/14/23 around 7:00 AM, she received a snapshot of a progress note from LVN B (worked 08/13/23 7P - 7A shift) via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning (08/14/23) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had an UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for a higher level of care on 08/17/23. During an interview on 09/25/23 at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room (08/17/23) when Resident #1 was sent out to hospital. Resident #1 did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on 09/25/23 at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before being sent to the hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident's clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative were examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize a change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever (could not state a specific date and time, referred to the week of 08/13/23 - 08/17/23) that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON stated nurses should document when the nurse reviewed lab results, notified the MD, and if orders were received. The DON indicated when the MD wrote orders for labs, the primary nurse completed a lab request. The DON said her expectations were for the nurse to review and notify the MD as soon as lab results were received and if any new orders were received, they should be carried out and documented. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI (before transferred to hospital). The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on 09/25/23 at 1:37 PM, a family member stated concerns started on 08/10/23 when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in January 2021 with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on 08/13/23. The family member stated the fever continued until 08/15/23, which at that time, Resident #1 had a low-grade fever of 99.8 degrees (Fahrenheit). The family member said that they were notified on 08/16/23 that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and (family member) wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, her heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on 8/18/2023, that nothing could be done, and the resident would benefit from palliative care. On 08/24/23, Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on 8/26/2023. The family member said that Resident #1 passed away because of the sepsis. During an interview on 09/25/23 at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when they provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident, not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine the cause of the change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about the resident's clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1, that she appeared lethargic (lack of energy), didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on 10/02/23 at 12:41 PM, LVN A said that she was familiar with Resident #1 and her care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any were given. LVN A said signs of an UTI were strong smelling urine, urine that looked cloudy, a fever, and the resident may become confused. LVN A said that she worked on 08/14/23 and was informed in report that Resident #1's fc was removed because it kept leaking. LVN A said that the reporting nurse [LVN B] said that Resident #1 threw up overnight once and had a fever. LVN A said that the NP saw Resident #1 in the early afternoon (08/14/23) and wrote orders for labs and an UA with C & S. LVN A said that she collected the urine specimen and called the lab company to schedule the lab draw and pick up the urine specimen. LVN A said that when she collected Resident #1's urine specimen, the urine had a foul smell. LVN A said that the procedure for lab tests is to enter the order, complete a requisition, and call the laboratory to schedule. LVN A said that the nurse checked the resident chart for the lab results. If the lab results were not reported by the end of their shift, the nurse should give report to the oncoming nurse to check for lab results. Once the lab results are received, electronically sent directly to the resident chart by the lab, the nurse will review and immediately notify the MD that the results are ready for review or inform of any abnormal/critical lab results. LVN A said the MD is notified via the messaging app or if critical lab results, the nurse must call the MD, and document notification/communication with the provider. LVN A said that she was not assigned to Resident #1 the next day (08/15/23) when the labs were scheduled to be drawn and results expected to return. Resident #1's vital signs were reviewed with LVN A and attention directed to the temperature summary that reflected an elevated temperature entered by LVN A and the MAR revealed LVN A administered acetaminophen to Resident #1 on 08/15/23. LVN A stated that she did not recall working on that day and if she worked, she would have checked for the lab results and notified the MD. During a follow up interview on 10/02/23 at 1:27 PM, LVN A said that she checked with the staffing coordinator and verified she worked on 08/15/23 and was assigned to Resident #1. LVN A said that she did know how Resident #1's labs were missed and not reviewed. LVN A said that the risk to a resident if labs were not reviewed in a timely manner would be in a delay in treatment and worsening of an infection. During an interview on 10/02/23 at 7:06 PM, LVN B said that she worked the evening shift, 7P - 7A and was familiar with Resident #1 and her care needs as the primary assigned nurse. LVN B said that Resident #1 was totally dependent for ADLs, confused, could respond to questions with a head nod/shake or answer yes or no, and had a FC that was removed. The FC was scheduled to be changed every 3 weeks or PRN. LVN B said that the CNA was responsible for providing catheter care during incontinent care. The task was on the MAR, and the nurse had to sign off nightly that the CNA performed catheter care using baby shampoo. LVN B said that she assisted the CNA with catheter care nightly, so she would assess if there was any trauma, signs, or symptoms of infection. LVN B said she gently tugged on the catheter tubing at the insert site to check for placement and checked if the balloon was inflated. LVN B said there was an order to encourage Resident #1 to drink fluids because she did not drink enough water, and there was sedimentation often noted in the urine. LVN B said that she flushed Resident #1's FC every night with 60 cc NS and monitored urine output per orders to prevent catheter complications. LVN B said the risk of not flushing the catheter would cause problems such as, catheter leakage, blocked catheter, catheter coming out, or an infection. LVN B said s/sx of an UTI included fever, sleepiness, decreased urine output, dark, foul smelling urine. LVN B said that the MD should be notified immediately. LVN B said that she worked on 08/13/23, 7P - 7A. Resident #1's progress notes were reviewed with LVN B. LVN B acknowledged she entered the progress note on 08/14/23 at 5:12 AM that reflected Resident #1 had a fever and threw up brownish partially digested food. LVN B said she did not recall the specific time. LVN B denied the emesis appeared like coffee grounds (dark brown in color with a lumpy texture. The appearance comes from old and coagulated [solid or semisolid state] blood in the GI tract). LVN B said Resident #1 threw up partially digested f[TRUNCATED]