**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 8 residents (Residents #39 and #4) reviewed for abuse. The facility did not take measures to prevent physical abuse between R#4 and R#39; R#39 was bit on the upper thigh and struck with a bed remote and call light by R#4. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. The findings were: Resident #39: Record review of Resident #39's face sheet, dated 10/15/23, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cardiomegaly (an enlarged heart), essential (primary) hypertension (high blood pressure), cerebral ischemia (results from impaired blood flow to the brain), anxiety disorder, unspecified ( a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #39's MDS assessment, dated 09/29/23, revealed Resident #39 had a BIMS score of 14, indicating intact cognition. Record review of Resident #39's care plan revealed a focus of, I have impaired cognitive function/or impaired though process related to cerebral ischemia. Record review of Resident #39's skin: abrasion/bruise/edema/mole/rash document dated 09/23/23 completed by RNS revealed Resident #39 had dark purple bruise to left and right hand, dark purple bruising to right forearm, a scratch noted to inferior aspect of left eye, redness to right shin and right knee and a bite mark to right lateral thigh and a scratch noted to right inner aspect of thigh/knee area. Record review of Resident #39's nursing notes dated 09/23/23 at 1:40PM by RNS revealed she was called by LVN P to Resident #4's room which she shared with Resident #39. RNS's nursing note stated she went to Residents #4 and 39's room and observed Resident #4 was being physically and verbally aggressive with Resident #39 with Resident #4 swinging bed remote at Resident #39's bilateral legs. RNS's nursing note stated a Head to toe assessment was performed with noted dark purple bruising to right forearm, dark purple bruise to left and right hand. Redness noted to right shin, right knee and bite mark to right lateral thigh. Scratch noted to inferior aspect of left eye. Scratch noted to right inner aspect of thigh/knee area. Resident #4 At time of the investigation Resident #4 was no longer in the facility, as per record review of Resident #4's face sheet on 10/15/23 Resident #4 was discharged from facility on 09/27/23 Record review of Resident #4's face sheet, dated 10/15/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and was discharged on 09/27/23 with diagnoses that included: Acute diastolic (occurs when left ventricle muscle becomes stiff or thickened) (congestive) heart failure ( the heart does not pump blood as well as it should ), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), current episode depressed, moderate, dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere, moderate, with mood disturbance, pneumonia (infection that affects one or both lungs), unspecified organism and type 2 diabetes mellitus (high blood sugar) with other specified complication. Record review of Resident #4's 5- day MDS assessment, dated 08/17/23, revealed Resident #4 had a BIMS score of 04, indicating severe cognitive impairment. Record review of Resident #4's care plan did have specific focuses regarding her anti-depressant and anticonvulsant medication but did not address her history of aggression. Resident #4's care plan had a focus of I use anticonvulsant medication as a mood stabilizer related to Dementia with mood disturbances; Bipolar and I require anti-depressant medication related to diagnosis of Depression which had an intervention to Monitor/document/report to MD prn ongoing signs and symptoms of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, all which had a created date of 08/24/23 and an initiated date of 10/14/23 Record review of Resident #4's hospital paper work submitted as part of her referral revealed a history of present illness from admission date 07/31/23 stating This lady is a psychiatric patient by all means who requires psychiatric attention. Not too long ago she was admitted for psychiatric treatment after an overdose and several episodes of fights and aggression at home with husband and others who may be there. Last week she was here in the emergency room for the same reason. It also included a hospital progress note for Resident #4 stating there was an open legal case for domestic abuse. Record review of Resident #4's nursing notes dated 09/23/23 at 1:40PM by RNS revealed she was called by LVN P to Resident #4's room which she shared with Resident #39. RNS's nursing note stated she went to Residents #4 and 39's room and observed Resident #4 swinging bed remote at Resident #39 striking him multiple times. During an interview on 10/11/23 at 5:10pm with the DON and ADM they both stated they were not aware of any APS case or Resident #4's behaviors prior to the incident between Resident #4 and #39 on 9/23/23. During an interview with the Admissions Coordinator at the facility on 10/11/23 at 3:25pm she stated Resident #4 had originally sent over paper work for admission months before her recent admission on [DATE] and stated that paperwork did include resident #4's behaviors and aggression towards Resident #39 and stated she was denied admission. The Admissions Coordinator stated when they received referral paper work for Resident #4's recent admission on [DATE] the paper work was submitted under a different name, she stated one of Resident #4's last names had been switched around or removed. The Admissions Coordinator could not provide any documentation of the original paperwork submitted for admission before current admission on [DATE] and stated because it was a denial that paperwork was not uploaded into any chart. During an interview with the responsible party for both Resident #4 and #39 on 10/11/23 at 4:25pm she stated Resident #4 had a history of aggression towards Resident #39 and had previously hit her as well. The responsible party for both Resident #4 and #39 stated the Medical Director knew Resident #4 was aggressive. The responsible party for both Resident #4 and #39 stated 2 or 3 days after Resident #39 was admitted to the facility she went to speak to the Admissions Coordinator at the facility and thought she had told her that Resident #4 was aggressive and that she was scared that Resident #4 would do something to Resident #39. The responsible party for both Resident #4 and #39 stated the Admissions Coordinator told her that Resident #4 and #39 would be fine and that nothing would happen. During an interview with the Admissions Coordinator at the facility on 10/11/23 at 4:50pm she stated there was nothing on Resident #4's records or referral about aggression. The Admissions Coordinator stated family for Resident #4 had not told her about aggression. The Admissions Coordinator stated she was not in communication with the responsible party for both Resident #4 and Resident #39 until Resident #39 was admitted to the facility and stated the only thing the responsible party for both Resident #4 and Resident #39 told her was that Resident #4 and #39 had a very complicated relationship. The Admissions Coordinator at the facility stated the process for reviewing an admission was, that everything was sent to Central Admissions and from there if there was any identified behavior on the paperwork it would be sent to herself, ADM and DON. The Admissions Coordinator stated there were no behaviors identified on either Resident #4 or #39. During an interview with Resident #39 on 10/11/23 at 4:25pm he stated Resident #4 had come to his bed side while he was in his bed and stated Resident #4 started hitting him on the arm with the call light and bit him on the leg after he put his arms up to defend himself. Resident #39 stated he felt fine with Resident #4 until she started to get mad on the day of the incident. During an interview with the Centralized Admissions Nurse on 10/12/23 at 12:08 pm he stated when reviewing referrals, he reviewed the documentation the hospital provides such as physician notes, therapy evaluations, medication records, specific skilled services they were requesting. The Centralized Admissions Nurse stated what he reviewed was documented under Resident #4's chart titled, referral. The Centralized Admissions Nurse stated he had reviewed Resident #4's referral documentation and stated he had concerns regarding history of bipolar disorder, mention of aggressive behavior, and dementia. The Centralized Admissions Nurse stated these concerns would have been sent over to the DON, ADM and the Liaison. The Centralized Admissions Nurse stated the Liaison completed an onsite assessment of Resident #4 on 08/08/23 at the hospital. The Centralized Admissions Nurse stated the Liaisons onsite included making sure Resident #4 was not on any chemical or physical restraints, was not a 1:1 supervision, speaking with direct care staff and asking about any concerns. The Centralized Admissions Nurse stated during those interviews conducted by the Liaison there were no concerns, and it was identified she was participating with therapy and at that point that decided to move forwards. During an interview with the Liaison 10/12/23 at 12:44pm she stated referrals who are categorized as yellow would require an onsite evaluation on the patient due to concerns of history of behaviors and elopement. The Liaison stated Resident #4 required an onsite evaluation that included her speaking with nurses, attending staff and therapy, she stated through her evaluation she identified Resident #4 was friendly, alert x4, talkative, kind and as per nurse she did have some episodes of confusion but did not with her. The Liaison stated her report was that there were no behaviors and no elopement. The Liaison stated the email from the Centralized Admissions Nurse regarding having her assess Resident #4 for any active behaviors or elopement had also been carbon copied to the ADM, DON, and Admissions Coordinator and stated they were aware of the behaviors being assessed by her. During an interview with the Medical Director on 10/12/23 at 6:21pm he was asked if he was aware of Resident #4's history of aggression towards Resident #39, he stated he had known Resident #4 and #39 for years and stated, this has been going on for years. The Medical Director stated Resident #4 and #39 previously lived together and stated Resident #4 and #39 wanted to be together and did not want to be kept apart so he said it was okay to put them together. When asked if he notified the facility of Resident #4's history of aggression he stated he thought it was written in his discharge summary for Resident #4 and stated the facility was aware that Resident #4 was bipolar. The Medical Director stated Resident #4 was a psych patient and needed to be admitted somewhere she could be monitored, and medication would be given on time and that had a psychologist and psychiatrist available on call to be there for a crisis. The medical director stated Resident #4 was aggressive to those around her by yelling, and would only hit, Resident #39. LVN P was attempted to be reached for telephone interview on 10/13/23 at 9:03am and 9:57am with no answer, voicemail was left however phone call was not returned. During an interview on 10/13/23 at 9:58am with RNS she stated on 9/23/23 she was called over to Resident #4 and #39's by LVN P. RNS stated she observed Resident #4 swinging the bed remote at Resident #39 hitting him on the legs. RNS stated they separated Resident #4 and #39 and checked on Resident #39 who told her Resident #4 had hit him everywhere with both the call light and the bed remote. RNS stated Resident #39 had redness to lower legs and knees and had a bite mark to upper thigh which she stated Resident #4 admitted to doing and Resident #39 confirmed. RNS stated after she separated Resident #4 and Resident #39 she called the doctor to speak with Resident #4 and notify him that she was being aggressive, RNS stated Resident #4 had tried to hit her and slap the phone out of RNS's hand. RNS state Resident #4 cornered her and was able to hit her and stated she believed Resident #4 turned around and had bit and hit LVN P. RNS stated she was not aware of any aggressive behaviors prior to the incident on 9/23/23. RNS stated she spoke to a family member of Resident #4 who stated that was their relationship at home and an APS (Adult Protective Services) worker who was at the building that day had told her that they had previous cases with Resident #4 and #39 for almost 5 years regarding physical arguing. RNS did not provide a name for APS worker. RNS stated Resident #4 had not exhibited similar behaviors towards Resident #39 before incident on 09/23/23. RNS stated Resident #4 only had her moods with refusing medication but that was the only extent of her behaviors. RNS stated she could not recall if Resident #4 had monitoring for behaviors associated with bipolar disorder. RNS stated if a resident had an antipsychotic or antidepressant or anti-convulsant then they would have a monitoring order for sleeplessness, agitation and stated she did not think it included aggression but more restlessness and insomnia. RNS stated she had done routine checks that included checking on Resident #4 and providing medication. RNS stated she always checked for any behaviors residents demonstrated and would have to notify the appropriate person if any changes were identified. During an interview with the ADM on 10/14/23 at 12:09PM he stated he, and facility staff had been trained over abuse identification and prevention, stating they were trained annually. The ADM stated a fracture, spiral fracture or bruising was considered physical abuse. The ADM stated Resident #4 had struck Resident #39 with the bed remote and had bit Resident #39's thigh. The ADM was asked if he considered the incident between Residents #4 and #39 abuse and he stated it was borderline. The ADM stated Resident #39 had a bite to thigh and bruising to left arm. The ADM stated nobody had made him aware of Resident #4's history of aggressive behaviors before the incident. The ADM stated he was made aware of Resident #4's behaviors after the incident when APS spoke to him and told him stories of incidents in the home setting. The ADM stated he was able to review the resident chart but did not review Resident #4's referral documents in that detail because the Central admission nurse handled that. The ADM stated he did not think there was an indication that Resident #4 had aggressive behaviors. The ADM stated the Medical Director had worked with Resident #4 and #39 previously and stated he could only speculate he was aware of Resident #4's history of aggressive behaviors but could not speak for him. The ADM stated, the Central Admissions nurse had not notified him of Resident #4 having violent behavior. The ADM stated Resident #39 was not scared of Resident #4. The ADM was not aware of Resident #4's care plan information, stating Resident #4 had no behaviors. The ADM stated nurses monitored Resident #4 stated they were with her every day stating any indication of behaviors they would have flagged. The ADM stated Resident #4 had a history of aggressive behaviors, but he was not aware. The ADM stated to ensure residents are free from abuse while in the facility they completed assessments, reviewed data from the physician and any other sources. The ADM stated the data did not indicate the actual violence that occurred, stating he did not know the extent of the aggression because there was not any indication of actual injury. The ADM stated their abuse policy stated they are to keep residents from abuse, he stated the policy was followed in this situation because Resident #39 did not indicate any fear and wanted to be with Resident #4. The ADM stated not identifying residents with history of aggressive behavior could cause a negative impact to other residents such as injury or death. During an interview with the DON on 10/14/23 at 2:35pm she stated her, and facility staff had been trained over abuse identification and prevention, stating training were completed 2 times a month. The DON stated hitting would be considered physical abuse. The DON stated she was notified that Resident #4 had started hitting Resident #39, the DON stated the incident between Resident #4 and #39 was considered physical abuse . The DON stated Resident #39 had purple discoloration of right forearm, left and right hand with redness noted to shin, and right knee. The DON stated Resident #39 was not scared of Resident #4 and wanted to be with her. The DON stated Resident #4 had no exhibited any aggressive behaviors before this incident on 09/23/23. The DON stated to ensure residents are free from abuse while in the facility she made sure that nobody with current aggressive behaviors were paired with anybody else, the DON stated it was effective in the situation with Resident #4 and #39 stating they moved Resident #4 and #39 . The DON stated not identifying residents with history of aggressive behaviors could impact residents because they could potentially be paired with somebody with behaviors who could potentially hurt their neighbors. During an interview with Resident #39 on 10/11/23 at 4:25pm he stated Resident #4 had come to his bed side while he was in his bed and stated Resident #4 started hitting him on the arm with the call light and bit him on the leg after he put his arms up to defend himself. Resident #39 stated he felt fine with Resident #4 until she started to get mad on the day of the incident. Record review of facility's policy titled, Abuse Guidance: Preventing, Identifying and Reporting with an implemented dated of February 2017 and a review date of 10/2022 stated, Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. And The community conducts the following steps to protect the residents, patients and veterans served . Residents should be screened upon referral to ensure that the current staffing patterns and staff expertise are suitable to provide the necessary care that the prospective resident requires, without the possibility of acts of abuse and neglect towards other residents The Administrator and DON were notified of an IJ on 10/13/23 at 3:53PM and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/14/23 at 4:00pm and included the following: Immediate Plan of Removal for: F656 Develop/Implement Comprehensive Plan of Care F600 Freedom from Abuse, Neglect, and Exploitation Immediate Response: Resident #4 was immediately assessed by nursing, medical care provided, and IDT continued to monitored resident to ensure his wellbeing. Resident # 39 was immediately assessed by the nurse and placed on 1:1 for monitoring and discharged for evaluation and treatment. Risk Response: All newly admitted residents who are admitted with historical aggressive behaviors may have been potentially affected. Director of Nursing/Designee will conduct an audit of all recent admissions hospital records to identify any concerns with aggressive behaviors towards others and will review the plan of care to ensure it appropriately reflects potential behavioral risks and/or will update the plan of care as indicated. Date completed: 10-14-23. Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of aggressive behaviors towards others. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential behavioral risks. Date completed: 10-15-23. Regional Nurse conducted re-educated to the Director of Nursing and Administrator regarding the Abuse and Neglect Preventing, Identifying and Preventing, admission process to include identifying potential behavioral risks; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place. Date completed: 10-14-23. Regional Nurse conducted re-educated to the Director of Nursing and Administrator regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being. Date completed: 10-14-23. System Response: Director of Nursing / Assistant Director of Nursing conducted re-educated to the IDT and all licensed nurses regarding the admission process and assessing residents to include identifying potential risks to include but not limited to behavioral risks, such as aggression or aggressive behaviors; thus, ensuring the identified risk is identified on the plan of care to ensure appropriate monitoring and supportive interventions are in place. Date completed: 10-15-23. Director of Nursing / Assistant Director of Nursing conducted re-educated to the IDT and all licensed nurses regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being. Date completed: 10-15-23. Education was provided to all staff regarding the process for monitoring, observing, and reporting all behavioral concerns to the licensed nurse in effort to provide needed care, protect the safety and well-being of all residents, to meet the resident's needs, have accurate documentation reflected in clinical record and to ensure appropriate interventions are in place as per facility's expected practices. Date completed: 10-15-23. Regional Nurse conducted re-educated to the Director of Nursing, Administrator admission Coordinator and Centralized Admissions Nurse regarding facility's updated referral/admission protocol effective immediately to implement a mandatory admission acceptance to ensure that all referrals with known physical aggression/aggressive behaviors are cleared by the Director of Nursing and/or Administrator prior to accepting the referral for admission. Date Completed: 10-14-23. Facility has updated its referral/admission protocol effective immediately to implement a mandatory admission acceptance to ensure that all referrals with known physical aggression/aggressive behaviors are cleared by the Director of Nursing and/or Administrator prior to accepting the referral for admission. Date Completed: 10-13-2023. Director of Nursing / Designee to conduct retraining for all team members prior to assuming next shift regarding: o Preventing, Identifying and Reporting Abuse and Neglect. Date Completed:10-15-23. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented. Date Completed: 10-15-2023. Monitoring Response: ADMIN/DNS/SW/ Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents. Director of Nursing/Designee will conduct random weekly audits of 1-3 new admission and/or readmissions' initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified aggressive behavioral or known physical aggression are noted in the plan of care and appropriate interventions are in place. Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. This plan will remain in place for the next 3 months and findings will be reported to the QAPI committee during monthly meeting for the next 3 months. The QAPI committee will then determine compliance or identify a need for additional training. The surveyor verification of the Plan of Removal on 10/15/23 and 10/16/23 was as follows: Record review of facility services revealed the DON, MDS and ADM had been trained over the new referral /admission protocol, RAI (Resident Assessment Instrument) process, identifying and preventing abuse and neglect, the admission process to include identifying potential behavior risks and risks that should be care planned and the importance of monitoring of supportive interventions. Record review of facility services revealed the Central Admissions nurse, Liaison, and the Admissions Coordinator, had been trained over the new referral/admission protocol. Record review of facility in services revealed 23 staff members that included nurses and the IDT (interdisciplinary team) were trained over the RAI process and the admission process to include assessing residents for behavioral risks and care planning the risks and supportive interventions. Record review of in services dated 10/13/23 revealed 90 team members were in serviced over, monitoring/observing/reporting behavioral concerns. Identifying and preventing abuse, neglect and exploitation. The importance of immediately completing the admission assessment/evaluation and exit seeking tool. Identifying exit seeking/elopement risk for all new admission/re-admission and utilizing a wander guard device if the person is identified as an elopement risk and what to o or response to a missing/unaccounted for resident/patient as per community process. Record review on 10/16/23 of resident charts and facility plan of removal revealed facility had identified 4 residents with behaviors, none of which were aggression. Record review of impacted 4 residents revealed all care plans were updated appropriately. A total of 47 staff members were interviewed on 10/15/23 and 10/16/23 across 3 separate shifts, from 6am-2pm, 2pm-10pm and 10pm-6am. Interviewed staff included both direct care and non-direct care staff. All staff members stated they had recently been trained over behaviors, documentation, facility procedures and abuse and neglect. All staff members interviewed were aware of what to do when identifying behaviors, who to report to and where to document identified behaviors. Staff were able to define abuse and neglect, staff gave examples of abuse and neglect, identify abuse and neglect, staff were aware of what to do when abuse and neglect was suspected and who to report to. In addition, nurses and leadership were aware of the admission process and RAI process. During an interview with the DON on 10/15/23 at 12:16pm she stated through audits and staff interviews the facility had identified residents with behaviors and had updated care plans appropriately. The DON stated they would be monitoring residents on a daily basis during morning meetings, through clinical reviews that would include reviewing the 24-hour report that would state any behaviors or changes. The DON stated residents care plans would be updated immediately in the morning meeting if needed. During an interview with the DON on 10/16/23 at around 9:00AM she stated they had identified 4 residents with behaviors however none of the behaviors identified were aggression. The DON stated care plans had been updated to reflect identified behaviors. During an interview with the Medical Director on 10/16/23 at 4:13pm he stated he was a part of a meeting over the weekend (10/14/23-10/15/23) with the facility that covered elopement, door alarms, strategies to monitor the doors, monitoring patients, behaviors and training of the staff to be aware and facility procedures. During an interview on 10/16/23 at 3:50PM with the Central Admissions nurse he stated he had been trained over the new referral/admission protocol and was aware of needing DON and/or ADM approval for approval/denial for new admissions. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 8 residents (Residents #39 and #4) reviewed for abuse. The facility did not take measures to prevent physical abuse between R#4 and R#39; R#39 was bit on the upper thigh and struck with a bed remote and call light by R#4. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. The findings were: Resident #39: Record review of Resident #39's face sheet, dated 10/15/23, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cardiomegaly (an enlarged heart), essential (primary) hypertension (high blood pressure), cerebral ischemia (results from impaired blood flow to the brain), anxiety disorder, unspecified ( a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #39's MDS assessment, dated 09/29/23, revealed Resident #39 had a BIMS score of 14, indicating intact cognition. Record review of Resident #39's care plan revealed a focus of, I have impaired cognitive function/or impaired though process related to cerebral ischemia. Record review of Resident #39's skin: abrasion/bruise/edema/mole/rash document dated 09/23/23 completed by RNS revealed Resident #39 had dark purple bruise to left and right hand, dark purple bruising to right forearm, a scratch noted to inferior aspect of left eye, redness to right shin and right knee and a bite mark to right lateral thigh and a scratch noted to right inner aspect of thigh/knee area. Record review of Resident #39's nursing notes dated 09/23/23 at 1:40PM by RNS revealed she was called by LVN P to Resident #4's room which she shared with Resident #39. RNS's nursing note stated she went to Residents #4 and 39's room and observed Resident #4 was being physically and verbally aggressive with Resident #39 with Resident #4 swinging bed remote at Resident #39's bilateral legs. RNS's nursing note stated a Head to toe assessment was performed with noted dark purple bruising to right forearm, dark purple bruise to left and right hand. Redness noted to right shin, right knee and bite mark to right lateral thigh. Scratch noted to inferior aspect of left eye. Scratch noted to right inner aspect of thigh/knee area. Resident #4 Record review of Resident #4's face sheet, dated 10/15/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and was discharged on 09/27/23 with diagnoses that included: Acute diastolic (occurs when left ventricle muscle becomes stiff or thickened) (congestive) heart failure ( the heart does not pump blood as well as it should ), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), current episode depressed, moderate, dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere, moderate, with mood disturbance, pneumonia (infection that affects one or both lungs), unspecified organism and type 2 diabetes mellitus (high blood sugar) with other specified complication. Record review of Resident #4's 5- day MDS assessment, dated 08/17/23, revealed Resident #4 had a BIMS score of 04, indicating severe cognitive impairment. Record review of Resident #4's care plan did have specific focuses regarding her anti-depressant and anticonvulsant medication but did not address her history of aggression. Resident #4's care plan had a focus of I use anticonvulsant medication as a mood stabilizer related to Dementia with mood disturbances; Bipolar and I require anti-depressant medication related to diagnosis of Depression which had an intervention to Monitor/document/report to MD prn ongoing signs and symptoms of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, all which had a created date of 08/24/23 and an initiated date of 10/14/23 Record review of Resident #4's hospital paper work submitted as part of her referral revealed a history of present illness from admission date 07/31/23 stating This lady is a psychiatric patient by all means who requires psychiatric attention. Not too long ago she was admitted for psychiatric treatment after an overdose and several episodes of fights and aggression at home with husband and others who may be there. Last week she was here in the emergency room for the same reason. It also included a hospital progress note for Resident #4 stating there was an open legal case for domestic abuse. Record review of Resident #4's nursing notes dated 09/23/23 at 1:40PM by RNS revealed she was called by LVN P to Resident #4's room which she shared with Resident #39. RNS's nursing note stated she went to Residents #4 and 39's room and observed Resident #4 swinging bed remote at Resident #39 striking him multiple times. During an interview on 10/11/23 at 5:10pm with the DON and ADM they both stated they were not aware of any APS case or Resident #4's behaviors prior to the incident between Resident #4 and #39 on 9/23/23. During an interview with the Admissions Coordinator at the facility on 10/11/23 at 3:25pm she stated Resident #4 had originally sent over paper work for admission months before her recent admission on [DATE] and stated that paperwork did include resident #4's behaviors and aggression towards Resident #39 and stated she was denied admission. The Admissions Coordinator stated when they received referral paper work for Resident #4's recent admission on [DATE] the paper work was submitted under a different name, she stated one of Resident #4's last names had been switched around or removed. The Admissions Coordinator could not provide any documentation of the original paperwork submitted for admission before current admission on [DATE] and stated because it was a denial that paperwork was not uploaded into any chart. During an interview with the responsible party for both Resident #4 and #39 on 10/11/23 at 4:25pm she stated Resident #4 had a history of aggression towards Resident #39 and had previously hit her as well. The responsible party for both Resident #4 and #39 stated the Medical Director knew Resident #4 was aggressive. The responsible party for both Resident #4 and #39 stated 2 or 3 days after Resident #39 was admitted to the facility she went to speak to the Admissions Coordinator at the facility and thought she had told her that Resident #4 was aggressive and that she was scared that Resident #4 would do something to Resident #39. The responsible party for both Resident #4 and #39 stated the Admissions Coordinator told her that Resident #4 and #39 would be fine and that nothing would happen. During an interview with the Admissions Coordinator at the facility on 10/11/23 at 4:50pm she stated there was nothing on Resident #4's records or referral about aggression. The Admissions Coordinator stated family for Resident #4 had not told her about aggression. The Admissions Coordinator stated she was not in communication with the responsible party for both Resident #4 and Resident #39 until Resident #39 was admitted to the facility and stated the only thing the responsible party for both Resident #4 and Resident #39 told her was that Resident #4 and #39 had a very complicated relationship. The Admissions Coordinator at the facility stated the process for reviewing an admission was, that everything was sent to Central Admissions and from there if there was any identified behavior on the paperwork it would be sent to herself, ADM and DON. The Admissions Coordinator stated there were no behaviors identified on either Resident #4 or #39. During an interview with Resident #39 on 10/11/23 at 4:25pm he stated Resident #4 had come to his bed side while he was in his bed and stated Resident #4 started hitting him on the arm with the call light and bit him on the leg after he put his arms up to defend himself. Resident #39 stated he felt fine with Resident #4 until she started to get mad on the day of the incident. During an interview with the Centralized Admissions Nurse on 10/12/23 at 12:08 pm he stated when reviewing referrals, he reviewed the documentation the hospital provides such as physician notes, therapy evaluations, medication records, specific skilled services they were requesting. The Centralized Admissions Nurse stated what he reviewed was documented under Resident #4's chart titled, referral. The Centralized Admissions Nurse stated he had reviewed Resident #4's referral documentation and stated he had concerns regarding history of bipolar disorder, mention of aggressive behavior, and dementia. The Centralized Admissions Nurse stated these concerns would have been sent over to the DON, ADM and the Liaison. The Centralized Admissions Nurse stated the Liaison completed an onsite assessment of Resident #4 on 08/08/23 at the hospital. The Centralized Admissions Nurse stated the Liaisons onsite included making sure Resident #4 was not on any chemical or physical restraints, was not a 1:1 supervision, speaking with direct care staff and asking about any concerns. The Centralized Admissions Nurse stated during those interviews conducted by the Liaison there were no concerns, and it was identified she was participating with therapy and at that point that decided to move forwards. During an interview with the Liaison 10/12/23 at 12:44pm she stated referrals who are categorized as yellow would require an onsite evaluation on the patient due to concerns of history of behaviors and elopement. The Liaison stated Resident #4 required an onsite evaluation that included her speaking with nurses, attending staff and therapy, she stated through her evaluation she identified Resident #4 was friendly, alert x4, talkative, kind and as per nurse she did have some episodes of confusion but did not with her. The Liaison stated her report was that there were no behaviors and no elopement. The Liaison stated the email from the Centralized Admissions Nurse regarding having her assess Resident #4 for any active behaviors or elopement had also been carbon copied to the ADM, DON, and Admissions Coordinator and stated they were aware of the behaviors being assessed by her. During an interview with the Medical Director on 10/12/23 at 6:21pm he was asked if he was aware of Resident #4's history of aggression towards Resident #39, he stated he had known Resident #4 and #39 for years and stated, this has been going on for years. The Medical Director stated Resident #4 and #39 previously lived together and stated Resident #4 and #39 wanted to be together and did not want to be kept apart so he said it was okay to put them together. When asked if he notified the facility of Resident #4's history of aggression he stated he thought it was written in his discharge summary for Resident #4 and stated the facility was aware that Resident #4 was bipolar. The Medical Director stated Resident #4 was a psych patient and needed to be admitted somewhere she could be monitored, and medication would be given on time and that had a psychologist and psychiatrist available on call to be there for a crisis. The medical director stated Resident #4 was aggressive to those around her by yelling, and would only hit, Resident #39. LVN P was attempted to be reached for telephone interview on 10/13/23 at 9:03am and 9:57am with no answer, voicemail was left however phone call was not returned. During an interview on 10/13/23 at 9:58am with RNS she stated on 9/23/23 she was called over to Resident #4 and #39's by LVN P. RNS stated she observed Resident #4 swinging the bed remote at Resident #39 hitting him on the legs. RNS stated they separated Resident #4 and #39 and checked on Resident #39 who told her Resident #4 had hit him everywhere with both the call light and the bed remote. RNS stated Resident #39 had redness to lower legs and knees and had a bite mark to upper thigh which she stated Resident #4 admitted to doing and Resident #39 confirmed. RNS stated after she separated Resident #4 and Resident #39 she called the doctor to speak with Resident #4 and notify him that she was being aggressive, RNS stated Resident #4 had tried to hit her and slap the phone out of RNS's hand. RNS state Resident #4 cornered her and was able to hit her and stated she believed Resident #4 turned around and had bit and hit LVN P. RNS stated she was not aware of any aggressive behaviors prior to the incident on 9/23/23. RNS stated she spoke to a family member of Resident #4 who stated that was their relationship at home and an APS (Adult Protective Services) worker who was at the building that day had told her that they had previous cases with Resident #4 and #39 for almost 5 years regarding physical arguing. RNS did not provide a name for APS worker. RNS stated Resident #4 had not exhibited similar behaviors towards Resident #39 before incident on 09/23/23. RNS stated Resident #4 only had her moods with refusing medication but that was the only extent of her behaviors. RNS stated she could not recall if Resident #4 had monitoring for behaviors associated with bipolar disorder. RNS stated if a resident had an antipsychotic or antidepressant or anti-convulsant then they would have a monitoring order for sleeplessness, agitation and stated she did not think it included aggression but more restlessness and insomnia. RNS stated she had done routine checks that included checking on Resident #4 and providing medication. RNS stated she always checked for any behaviors residents demonstrated and would have to notify the appropriate person if any changes were identified. During an interview with the ADM on 10/14/23 at 12:09PM he stated he, and facility staff had been trained over abuse identification and prevention, stating they were trained annually. The ADM stated a fracture, spiral fracture or bruising was considered physical abuse. The ADM stated Resident #4 had struck Resident #39 with the bed remote and had bit Resident #39's thigh. The ADM was asked if he considered the incident between Residents #4 and #39 abuse and he stated it was borderline. The ADM stated Resident #39 had a bite to thigh and bruising to left arm. The ADM stated nobody had made him aware of Resident #4's history of aggressive behaviors before the incident. The ADM stated he was made aware of Resident #4's behaviors after the incident when APS spoke to him and told him stories of incidents in the home setting. The ADM stated he was able to review the resident chart but did not review Resident #4's referral documents in that detail because the Central admission nurse handled that. The ADM stated he did not think there was an indication that Resident #4 had aggressive behaviors. The ADM stated the Medical Director had worked with Resident #4 and #39 previously and stated he could only speculate he was aware of Resident #4's history of aggressive behaviors but could not speak for him. The ADM stated, the Central Admissions nurse had not notified him of Resident #4 having violent behavior. The ADM stated Resident #39 was not scared of Resident #4. The ADM was not aware of Resident #4's care plan information, stating Resident #4 had no behaviors. The ADM stated nurses monitored Resident #4 stated they were with her every day stating any indication of behaviors they would have flagged. The ADM stated Resident #4 had a history of aggressive behaviors, but he was not aware. The ADM stated to ensure residents are free from abuse while in the facility they completed assessments, reviewed data from the physician and any other sources. The ADM stated the data did not indicate the actual violence that occurred, stating he did not know the extent of the aggression because there was not any indication of actual injury. The ADM stated their abuse policy stated they are to keep residents from abuse, he stated the policy was followed in this situation because Resident #39 did not indicate any fear and wanted to be with Resident #4. The ADM stated not identifying residents with history of aggressive behavior could cause a negative impact to other residents such as injury or death. During an interview with the DON on 10/14/23 at 2:35pm she stated her, and facility staff had been trained over abuse identification and prevention, stating training were completed 2 times a month. The DON stated hitting would be considered physical abuse. The DON stated she was notified that Resident #4 had started hitting Resident #39, the DON stated the incident between Resident #4 and #39 was considered physical abuse . The DON stated Resident #39 had purple discoloration of right forearm, left and right hand with redness noted to shin, and right knee. The DON stated Resident #39 was not scared of Resident #4 and wanted to be with her. The DON stated Resident #4 had no exhibited any aggressive behaviors before this incident on 09/23/23. The DON stated to ensure residents are free from abuse while in the facility she made sure that nobody with current aggressive behaviors were paired with anybody else, the DON stated it was effective in the situation with Resident #4 and #39 stating they moved Resident #4 and #39 . The DON stated not identifying residents with history of aggressive behaviors could impact residents because they could potentially be paired with somebody with behaviors who could potentially hurt their neighbors. During an interview with Resident #39 on 10/11/23 at 4:25pm he stated Resident #4 had come to his bed side while he was in his bed and stated Resident #4 started hitting him on the arm with the call light and bit him on the leg after he put his arms up to defend himself. Resident #39 stated he felt fine with Resident #4 until she started to get mad on the day of the incident. Record review of facility's policy titled, Abuse Guidance: Preventing, Identifying and Reporting with an implemented dated of February 2017 and a review date of 10/2022 stated, Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. And The community conducts the following steps to protect the residents, patients and veterans served . Residents should be screened upon referral to ensure that the current staffing patterns and staff expertise are suitable to provide the necessary care that the prospective resident requires, without the possibility of acts of abuse and neglect towards other residents The Administrator and DON were notified of an IJ on 10/13/23 at 3:53PM and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/14/23 at 4:00pm and included the following: Immediate Plan of Removal for: F656 Develop/Implement Comprehensive Plan of Care F600 Freedom from Abuse, Neglect, and Exploitation Immediate Response: Resident #4 was immediately assessed by nursing, medical care provided, and IDT continued to monitored resident to ensure his wellbeing. Resident # 39 was immediately assessed by the nurse and placed on 1:1 for monitoring and discharged for evaluation and treatment. Risk Response: All newly admitted residents who are admitted with historical aggressive behaviors may have been potentially affected. Director of Nursing/Designee will conduct an audit of all recent admissions hospital records to identify any concerns with aggressive behaviors towards others and will review the plan of care to ensure it appropriately reflects potential behavioral risks and/or will update the plan of care as indicated. Date completed: 10-14-23. Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of aggressive behaviors towards others. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential behavioral risks. Date completed: 10-15-23. Regional Nurse conducted re-educated to the Director of Nursing and Administrator regarding the Abuse and Neglect Preventing, Identifying and Preventing, admission process to include identifying potential behavioral risks; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place. Date completed: 10-14-23. Regional Nurse conducted re-educated to the Director of Nursing and Administrator regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being. Date completed: 10-14-23. System Response: Director of Nursing / Assistant Director of Nursing conducted re-educated to the IDT and all licensed nurses regarding the admission process and assessing residents to include identifying potential risks to include but not limited to behavioral risks, such as aggression or aggressive behaviors; thus, ensuring the identified risk is identified on the plan of care to ensure appropriate monitoring and supportive interventions are in place. Date completed: 10-15-23. Director of Nursing / Assistant Director of Nursing conducted re-educated to the IDT and all licensed nurses regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being. Date completed: 10-15-23. Education was provided to all staff regarding the process for monitoring, observing, and reporting all behavioral concerns to the licensed nurse in effort to provide needed care, protect the safety and well-being of all residents, to meet the resident's needs, have accurate documentation reflected in clinical record and to ensure appropriate interventions are in place as per facility's expected practices. Date completed: 10-15-23. Regional Nurse conducted re-educated to the Director of Nursing, Administrator admission Coordinator and Centralized Admissions Nurse regarding facility's updated referral/admission protocol effective immediately to implement a mandatory admission acceptance to ensure that all referrals with known physical aggression/aggressive behaviors are cleared by the Director of Nursing and/or Administrator prior to accepting the referral for admission. Date Completed: 10-14-23. Facility has updated its referral/admission protocol effective immediately to implement a mandatory admission acceptance to ensure that all referrals with known physical aggression/aggressive behaviors are cleared by the Director of Nursing and/or Administrator prior to accepting the referral for admission. Date Completed: 10-13-2023. Director of Nursing / Designee to conduct retraining for all team members prior to assuming next shift regarding: o Preventing, Identifying and Reporting Abuse and Neglect. Date Completed:10-15-23. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented. Date Completed: 10-15-2023. Monitoring Response: ADMIN/DNS/SW/ Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents. Director of Nursing/Designee will conduct random weekly audits of 1-3 new admission and/or readmissions' initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified aggressive behavioral or known physical aggression are noted in the plan of care and appropriate interventions are in place. Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. This plan will remain in place for the next 3 months and findings will be reported to the QAPI committee during monthly meeting for the next 3 months. The QAPI committee will then determine compliance or identify a need for additional training. The surveyor verification of the Plan of Removal on 10/15/23 and 10/16/23 was as follows: Record review of facility services revealed the DON, MDS and ADM had been trained over the new referral /admission protocol, RAI (Resident Assessment Instrument) process, identifying and preventing abuse and neglect, the admission process to include identifying potential behavior risks and risks that should be care planned and the importance of monitoring of supportive interventions. Record review of facility services revealed the Central Admissions nurse, Liaison, and the Admissions Coordinator, had been trained over the new referral/admission protocol. Record review of facility in services revealed 23 staff members that included nurses and the IDT (interdisciplinary team) were trained over the RAI process and the admission process to include assessing residents for behavioral risks and care planning the risks and supportive interventions. Record review of in services dated 10/13/23 revealed 90 team members were in serviced over, monitoring/observing/reporting behavioral concerns. Identifying and preventing abuse, neglect and exploitation. The importance of immediately completing the admission assessment/evaluation and exit seeking tool. Identifying exit seeking/elopement risk for all new admission/re-admission and utilizing a wander guard device if the person is identified as an elopement risk and what to o or response to a missing/unaccounted for resident/patient as per community process. Record review on 10/16/23 of resident charts and facility plan of removal revealed facility had identified 4 residents with behaviors, none of which were aggression. Record review of impacted 4 residents revealed all care plans were updated appropriately. A total of 47 staff members were interviewed on 10/15/23 and 10/16/23 across 3 separate shifts, from 6am-2pm, 2pm-10pm and 10pm-6am. Interviewed staff included both direct care and non-direct care staff. All staff members stated they had recently been trained over behaviors, documentation, facility procedures and abuse and neglect. All staff members interviewed were aware of what to do when identifying behaviors, who to report to and where to document identified behaviors. Staff were able to define abuse and neglect, staff gave examples of abuse and neglect, identify abuse and neglect, staff were aware of what to do when abuse and neglect was suspected and who to report to. In addition, nurses and leadership were aware of the admission process and RAI process. During an interview with the DON on 10/15/23 at 12:16pm she stated through audits and staff interviews the facility had identified residents with behaviors and had updated care plans appropriately. The DON stated they would be monitoring residents on a daily basis during morning meetings, through clinical reviews that would include reviewing the 24-hour report that would state any behaviors or changes. The DON stated residents care plans would be updated immediately in the morning meeting if needed. During an interview with the DON on 10/16/23 at around 9:00AM she stated they had identified 4 residents with behaviors however none of the behaviors identified were aggression. The DON stated care plans had been updated to reflect identified behaviors. During an interview with the Medical Director on 10/16/23 at 4:13pm he stated he was a part of a meeting over the weekend (10/14/23-10/15/23) with the facility that covered elopement, door alarms, strategies to monitor the doors, monitoring patients, behaviors and training of the staff to be aware and facility procedures. During an interview on 10/16/23 at 3:50PM with the Central Admissions nurse he stated he had been trained over the new referral/admission protocol and was aware of needing DON and/or ADM approval for approval/denial for new admissions. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #100) reviewed for accidents and hazards: The facility failed to develop and implement interventions to prevent Resident #100's elopement from the facility. Resident #100 eloped from the facility and was found by the road having sustained abrasions, lacerations and a hematoma. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was removed on 10/16/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: Review of Resident #100's face sheet dated 10/15/23 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including, other specified arthritis (inflammation or swelling of joints), multiple sites, unspecified dementia (a group of thinking and social symptoms that interfere with daily functioning), moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other unspecified depressive episodes ( feeling sad, irritable, empty). cognitive communication deficit (difficulty with thinking and how someone uses language) and unsteadiness on feet. Resident #100 was not identified as her own responsible party. Review of Resident #100's MDS, dated [DATE], reflected a BIMS of 05, indicating severe cognitive impairment. It further reflected that Resident #10 did not require any mobility devices and when walking up to 150 feet required supervision or touching assistance. Resident #100's MDS reflect a 0 when asked is Has the resident wandered?, a 0 indicated wandering behavior had not been exhibited. Resident #100's MDS reflected she used a wander/elopement alarm daily. Record review of Resident #100's comprehensive care plan revealed Resident #100 had impaired cognitive function or impaired though processes related dementia with a created and initiated date of 09/12/23. Resident #100's care plan stated, I am exit seeking, I am at risk for elopement and/or wandering with unsafe boundaries related to dementia 9/30 elopement with a created and initiated date of 09/15/23 and a revision date of 10/05/23. Interventions included, 9/30 out to ER(emergency room) for check up; room change provided; with an initiation date of 10/05/23 and Assess my continued need for the wander guard use as indicated . Distract me from exit seeking by offering pleasant diversions, structured activities, food, conversation, television, book. I prefer the following: . I wear a wander guard device; confirm functioning of device & change device as indicated . Identify pattern of exit seeking: Intervene as appropriate in efforts to minimize behavior . Provide planned and engaging activities as well as activities to meet my needs such as toileting efforts and addressing thirst and hunger needs to prevent/minimize wandering and/or exit seeking attempts because the behavior may be related to a need that cannot be stated. All with an initiation date of 09/15/23. Record review of Resident #100's physician orders revealed an order to check functionality and visualization of wander guard/exit management system through wand or alarmed door QS (every shift) with a start date of 09/14/23 and that was active with no end date noted. Record review of Resident #100 September 2023 licensed nurse administration record revealed order had been completed and documented for every shift in September 2023 as ordered. Record review of Resident #100's exit seeking risk tool dated 09/15/23 completed by the DON revealed Resident #100 exhibited wandering and/or confused behavior, verbalized the need and /or desire to go home or to another location and has the ability to act on that verbalization, has a medical diagnosis associated with confusion which may indicate future likelihood for wandering and was physically able to exit on foot or by wheelchair. Wandering assessment identified Resident #100 did not display exit seeking behavior further stating, NO EXIT SEEKING AT THIS TIME, ONLY WANDERING BEHAVIOR. Record review of Resident #100's nursing notes with an effective date of 09/30/23 and 2:47pm written by RNS revealed she was called to 400 hall by NAIT L due to an activated door alarm. RNS stated her and LVN N went to reset the alarm and looked outside but did not see anyone. RNS stated she completed a resident check and noted Resident #100 was not in her room and went back outside and checked again but did not find the resident. RNS stated she searched inside the facility again and asked other nurses if they had seen Resident #100 but Resident #100 was not located. RNS stated her and LVN N went outside to check again and went down the street when someone was calling out behind her, she turned back and saw what appeared to be a person on the floor with people around and cars on the street. RNS ran to Resident #100 with LVN N and saw Resident #100 sitting on the curb past a vacant lot near offices who when asked where she was going stated she had left to go to the store. RNS identified Resident #100 was actively bleeding from nose and mouth, had a hematoma noted to right side of her forehead above the eyebrow, redness to nose, abrasion to left knee and laceration to the lower lip, Resident #100 was conscious and able to recall a family members phone number. 911 was activated at 3:00pm. Resident #100 was noted with good range of motion to all extremities and denied pain. Record review of Resident #100's hospital records dated 9/30/23 revealed a diagnosis of, contusion to left knee, contusion to right knee, facial abrasion, facial contusion, fall, traumatic hematoma of forehead and wrist sprain. Prescriptions given included acetaminophen 325mg (milligrams) with instructions of 650 MG by mouth every 4 hours as needed for pain for 5 days. Bacitracin/neomycin/polymyxin pramoxine top (triple antibiotics plus topical ointment) for 1 application to be applied topically 2 times for 3 days. Imaging results stated as pending. Record review of Resident #100's nursing noted completed by RNS on 09/30/23 at 6:33pm stated RNS received a call from hospital nurse who stated Resident #100 would be returning to facility and stated Resident #100 had cervical and facial CT scan, x-rays of left knee, left wrist which were all negative. Only finding was soft tissue swelling. New orders to be send for Tylenol 650MG PRN (as needed) and triple antibiotic ointment to be applied to abrasions. Record review of Resident #100's nursing noted completed by RNS on 09/30/23 at 7:37pm stated Resident #100 arrived back to facility after emergency room visit and was able to get out of family members truck and ambulate to her room, RNS completed a head to assessment that noted abrasion to nose, upper lip, left knee, left hand knuckle and right aspect of forehead. A Hematoma was noted to the right aspect of forehead and a laceration to inner lower lip. Resident #100 denied pain and could not recall falling or eloping. Resident #100 was placed on 15-minute monitoring and neuro check (assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired.) Record review of Resident #100's document titled Skin: Abrasion/Bruise/Edema/Mole/Rash dated 09/30/23 and signed by RNS on 10/01/23 revealed Resident #100 had abrasion to left hand knuckles, abrasion to left knee and a hematoma to right aspect of forehead, abrasion to nose, upper lip and laceration to inner aspect of lower lip that was first observed on 09/30/23. Record review of Resident #100's document titled Skin & Wound - Total Body Skin Assessment with an effective date of 09/30/23 at 7:37pm and signed by RNS on 10/01/23 revealed a total of 9 new wounds. During an interview an observation with the Maintenance Director on 10/11/23 between 9:52am and 10:15am noted a total of 9 doors, 2 doors identified as the service door and front door were equipped with similar alarm systems that required the alarm to be turned off at the door and at the nurse's station. All other 7 doors were equipment with a different type of alarm. Doors were tested with and without wander guard, all doors opened after a 15 second egress regardless of if using a wander guard or not. During an interview with the ADM on 10/11/23 at 10:12am he stated the front door and service door were equipped with a wander guard alarm while all other doors were equipped with a sound alarm. The ADM stated the service door and the front door were high traffic areas and that was why they were equipped those 2 doors with a wander guard alarm. It was identified through this information that the door Resident #100 eloped from in hall 400 door was equipped with a 15 second delayed egress and a stop alarm (manual annunciator) Record review of maintenance logbook documentation stating Resident Monitoring System: check operation of door monitors and patient wandering system. Marked done on time by (Maintenance supervisor) on September 22, 2023. Revealed 9 doors were tested and alert and alarm system are in working condition. Record Review of TULIP (HHSC online incident reporting application) on 10/10/23 at 5:00PM revealed the facility made a self-reported incident on 10/02/23 at 2:01pm regarding Resident #100's elopement. Record review of facility elopement training/in services completed prior to Resident #100's elopement revealed the facility had a training over elopement on 09/25/23 at 1:40pm. NAIT L was not on identified on attendance record. Record Review of facility elopement training/in services revealed NAIT L had not previously been trained before Resident #100's elopement on 09/30/23. Observation on 10/13/23 at 9:00am of surrounding streets revealed a 2-way street with a turning lane with a speed limit of 30 miles per hour. Observation of Resident #100 on 10/10/23 at 9:32am revealed scab to left knee, bruising under bilateral eyes, bruising to right side of forehead, bubbled skin tear area inside lower lip with scabbing noted on lower lip. Resident #100 was noted with a wander guard in place. During an interview on 10/10/23 at 9:32am with Resident #100 she stated she had a fall when she went alone to cross the street to go to the store. Resident #100 was unable to recall what happened after she was helped up but stated she had pain inside her lip. During an interview on 10/10/23 at 12:17 pm with NAIT L she stated on 09/30/23 she heard the alarm go off in the 400 hall back side door, she stated she went to put in the code to the key pad because normally a resident would click there but not go out. NAIT L stated she attempted to put in the code, but it did not work. NAIT L stated she proceeded to notify RNS and LVN N who both went to the door. NAIT L stated RNS fixed the door alarm, did a head count and checked every room in every hall but did not find Resident #100. NAIT L stated everyone went outside to search for Resident #100. NAIT L stated she did not look outside the door when responding to the door alarm because she is used to residents in the wheelchair just pushing the door. NAIT L stated she had been trained over elopement procedures and should have gone outside to check but stated she forgot and got the nurse instead, NAIT L stated she looked through the window. NAIT L stated everybody including herself was responsible for supervision of Resident #100 on 09/30/23. NAIT L stated Resident #100 had a wander guard in place at the time of elopement and stated everyone was responsible for ensuring it was in place and working. NAIT L stated door alarms were working on 09/30/23. NAIT L stated she was not aware where Resident #100 was found. NAIT L stated residents eloping could negatively impact them because they could get ran over or something even worse than that. During an interview with RNS on 10/10/23 at 1:16pm she stated when a door alarm goes off they need to check surroundings by the door and check if anybody is walking outside and if nobody is found they proceed to do a head count and check in rooms and have other nurses check residents who are elopement risks. RNS stated she went to Resident #100's room and did not see her, RNS stated she ran outside with a nurse and went towards a vacant lot in the back and towards the street and checked the sides and did not find anyone. RNS stated she went back into facility and searched again but stated no one saw Resident #100. RNS stated they began to search outside again and decided to go down the street because Resident #100 always said she wanted to go home and to her family members house who RNS stated lived close by. RNS stated she heard someone behind her saying, over here, over here and stated she saw a car in the middle of the street and a lady in the middle of the street. RNS stated once she got to the location, Resident #100 was sitting at the side the street. RNS stated Resident #100 told her she was just going to the store nearby. RNS stated she assessed Resident #100 and identified an abrasion to left knee, a hematoma to right upper forehead, laceration to inner lower lip, redness to nose and was bleeding from her nose and mouth. RNS stated Resident #100 was able to recall family members phone number which RNS stated she called but stated the call was not picked up. RNS stated she called 911. RNS stated there was 1 car that had pulled over and 1 that was on the side. RNS stated there were 2 ladies who were there with Resident #100 with 1 stating they did not see anything and the other stating she had only seen Resident #100 crawling on the street when she was turning. RNS stated the street where Resident #100 was found was accessible by cars with both coming and going lanes. RNS stated she had been previously trained over elopement and stated when they hear an alarm they had to go right aware and check surroundings and count residents and complete a walk through. RNS stated the alarm was working on 9/30/23 because they did hear the alarm. RNS stated when the alarm went off they had positive COVID (coronavirus disease) residents and had the double doors shut and stated the alarm did not sound as loud, stating she did not hear it right away. RNS stated NAIT L stated she had heard the alarm, but RNS was not sure if NAIT L had went outside. RNS stated once NAIT L called her that's when they went to check. RNS stated she was not too sure on what time Resident #100 exited the facility but stated she started going towards the alarm at 2:47pm and had found Resident #100 at 2:55pm with the ambulance arriving at 3:18pm. RNS stated everyone on the floor including nurses and aides were responsible for supervising Resident #100 on 09/30/23. RNS stated Resident #100 had a wander guard in place at time of elopement on 09/30/23. RNS stated the nurses were responsible for ensuring the wander guard was in place and working, stating nursing would check it per shift and document it on the MAR (Medication Administration Record). RNS stated everyone in general and maintenance were responsible for ensuring the door alarms were working, stating she was not sure how often they were checked but stated they were working that day. RNS stated as per family Resident #100 had a history of this behavior which was why Resident was placed in facility. RNS stated residents eloping could negatively impact the residents due to injury, and death if they are not gotten to on time and on a busy street they could get hit and lost or dehydrated. During an interview with the ADM on 10/14/23 at 11:57AM he stated he did not work on 09/30/23 when Resident #100 eloped from facility. The ADM stated RNS was responsible for supervising Resident #100. The ADM did not have the exact time Resident #100 exited the facility. The ADM stated he had not been told about Resident #100 verbalizing she wanted to leave the facility. The ADM stated Resident #100 had not eloped from the facility before 09/30/23. The ADM stated Resident #100 had a wander guard placed after assessment was completed and stated it had been care planned. The ADM stated nursing was responsible for completing that assessment. The ADM stated Resident #100 was cognitively impaired and had poor safety awareness. The ADM stated Resident #100 was able to ambulate on her own. The ADM stated staff were aware residents who are wandering/elopement risk through an elopement book that was kept at nurses station and included all the demographics of the residents so they could be identified, the ADM stated he believed there was also another system more on the clinical side. The ADM stated staff received elopement in services and drills, and stated they complete them yearly through an online training program and throughout the year as part of their emergency preparedness plan. The ADM stated staff did look outside the door but stated he did not know how far they did, he stated staff had not seen anyone in the parking lot. The ADM stated they should have gone outside to search. The ADM stated Resident #100 was found across the street and had a skin tear to lip and bruising to forehead. The ADM stated if you were to step outside the door and look to where Resident #100 was found your line of sight would have been obscured by the vehicles in the parking lot. The ADM stated Resident #100 was found in under 15 minutes. The ADM stated from what he gathered from staff Resident #100 was going to the store. He stated there was no other injuries identified at the hospital. The ADM stated the facility elopement policy and procedures stated to search the outside, complete an internal head count, check for resident inside facility. The ADM was asked if the facility's policy was followed in this situation, and he stated staff should have gone further out. The ADM was not sure why staff did not follow their policy and stated staff had been trained to do that. The ADM stated it was possible that NAIT L had not been trained. The ADM stated he monitored that staff provided the appropriate level of supervision for residents to prevent elopement by completing drills to ensure staff follow the process and maintain the resident's safety. During an interview with the DON on 10/14/23 at 2:22PM she stated she did not work on 09/30/23 when Resident #100 eloped from facility. The DON stated RNS, NAIT L, LVN N and NAIT O were responsible for supervising Resident #100. The DON stated Resident #100 was out of the facility for about 15 minutes. The DON stated to her knowledge Resident #100 had not verbalized she wanted to leave the facility. The DON stated Resident #100 had not eloped from the facility before 09/30/23. The DON stated Resident #100 would wander into the nurse's station but would not try and get out, the DON stated it had been care planned. The DON stated the nurse that placed the bracelet, herself or sometimes the MDS Coordinator was responsible for completing development assessments. The DON stated Resident #100 was cognitively impaired but was aware, alert but forgetful, stating she had dementia. The DON stated Resident #100 did not have impaired safety awareness. The DON stated Resident #100 was able to ambulate on her own. The DON stated staff were aware of residents who were wandering/elopement risks through a wander guard note book at nurses' station and included resident demographics and a picture of resident. The DON stated NAIT L notified nurse of door alarm and stated NAIT L did open the door and look outside and sated she also looked through the glass windows and then went to notify the nurses. The DON stated NAIT L should have done a done a search of the outside area. The DON stated if NAIT L had stepped outside and looked at the surrounding areas she would have seen Resident #100. The DON stated Resident #100 sustained abrasion to nose, upper lip, left knee, left hand knuckle, hematoma to right aspect of forehead and had some bleeding noted. The DON stated based on what nurses told her there was some cars that saw Resident #100 and assisted when nurses went to get Resident #100. The DON stated Resident #100 stated she was going to the store. The DON stated there were no other injuries identified at the hospital. The DON stated they placed Resident #100 on a 1:1 and did a room change to place her in front of the nurse's station and in front of HR (human resources) office. The DON stated they had a care plan meeting with the family and stated based on Resident #100's risk a secure unit would be beneficial. The DON stated Resident #100's family was going to be taking her home for private care. The DON stated the facility elopement policy and procedures stated staff should go outside, check surrounding areas, if no one was found then an internal head count should be completed to identify who was missing. The DON stated NAIT L had not been trained prior to Resident #100's elopement on 09/30/23. The DON stated their previous elopement drill was on 09/26/23 and stated NAIT L had not worked that day. However, the DON stated staff had been verbally educated that when they hear alarms they are to immediately go and see why the alarm was sounding and which alarm it was, the DON stated NAIT L had received this verbal training from her before Resident #100's elopement. The DON stated she monitored that staff provided the appropriate level of supervision for residents to prevent elopement with wander guards and stated drills and in services over elopement were completed periodically on different shift. The DON stated residents eloping from the facility could negatively impact them because they could fall. Record review of facility policy titled Elopement Response & Exit Seeking Management with an implementation date of 2019 and a reviewed date of January 2023 stated under section, A. Elopement Response: unable to locate resident. 1. If a resident is unable to be located or the alarms have sounded, immediately initiate a search of the entire community both inside and outside premises. The Administrator and DON were notified of an IJ on 10/13/23 at 3:53PM and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/14/23 at 4:00pm and included the following: Immediate Plan of Removal for: F689 Each resident receives adequate supervision and assistance devices to prevent accidents. Immediate Response: Elopement search had commenced, Resident #1 was noted nearby facility and nurse immediately assessed resident and resident #1 was sent to the ER for further evaluation and treatment. Identified team member was re-educated on the elopement concern: 1. Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol-Implementing inside and outside on grounds search when there is a risk of a missing resident or elopement of a resident. Risk Response: There are 8 out of 100 residents who require a wander guard monitoring device and who may be potentially affected. Director of Nursing/Designee will conduct an audit of all recent new admissions and readmission, reviewing the exiting seeking assessment in order to identify any concerns with exiting seeking or elopement risks and the IDT will review the plan of care to ensure it appropriately reflects potential elopement/exit seeking risks and/or will update the plan of care as indicated. Date completed: 10-14-23. Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of exiting seeking / elopement behaviors. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential exiting seeking / elopement risk noted. Date completed: 10-14-23. System Response: Director of Nursing / Designee to conduct retraining for all team members prior to assuming next shift regarding: o Inservice conducted on Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol o Identifying and Responding to Triggers to Prevent Elopement and Behaviors o Preventing, Identifying and Reporting Abuse and Neglect. Date Completed:10-15-23. Director of Nursing / Designee to conduct retraining to all licensed nurses prior to assuming next shift regarding: o Identifying exit seeking / elopement risk for all new admission/re-admissions and utilizing a wander guard device if the person is identified as an elopement risk. o What to do or response to a missing/unaccounted for resident/patient as per community's process. Immediately initiating a search of inside and outside of facility to search for resident as per facility's expected practice, Elopement Response Protocol reviewed. Date Completed:10-15-23. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented. Date Completed:10-15-23. Monitoring Response: ADMIN/DNS/SW/ Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents. Director of Nursing/Designee will conduct random weekly audits of 1-3 new admission and/or readmissions' initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified elopement risk are noted in the plan of care and appropriate interventions are in place. Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. Administrator/Director of Nursing/Designee will conduct Elopement / Missing Person Response Drills at least weekly on random shifts to ensure all shifts have had elopement drills in order to identify competency of TMs work all three shifts or to identify additional education needs. Drills will be conducted weekly for the next 3 months. This plan will remain in place for the next 3 months and findings will be reported to the QAPI committee during monthly meeting for the next 3 months. The QAPI committee will then determine compliance or identify a need for additional training. The surveyor verification of the Plan of Removal on 10/15/23 and 10/16/23 was as follows: During an interview with the DON on 10/15/23 at 12:16pm she stated through audits and staff interviews the facility identified a total of 6 residents appropriate for wander guards. The DON stated they will be completing elopement drills weekly for the next 3 months and would be monitoring residents on a daily basis during morning meetings, through clinical reviews that would include reviewing the 24 hour report that would state any behaviors or changes. The DON stated residents care plans would be updated immediately in the morning meeting if needed. During an interview with the ADM on 10/15/23 at 1:06pm he stated residents would be monitored by completing rounds, reviewing them during morning meetings, going over 24hour reports, census, admissions and discharges, nursing notes. The ADM stated elopement/missing person drills would be done weekly for the next 3 months. Record review on 10/16/23 of resident charts and facility plan of removal revealed facility had previously identified 8 residents who used a wander guard however, Resident #100 had been discharged and Resident #90 had been downgraded and had wander guard removed due to not exhibiting exit seeking behaviors. Resident #90's updated care plan reflected she was a wander risk but not exit seeking. Resident #90's updated exit seeking risk tool reflected she had been seen walking slowly in the hall way but has not been exhibiting exit seeking behaviors. All other 6 residents had updated exit seeking risk tools, and all 6 resident's care plans appropriately reflect exit seeking/wandering risk. Record review of in services dated 10/13/23 revealed 90 team members were in serviced over, monitoring/observing/reporting behavioral concerns. Elopement, specifically Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol, Identifying and Responding to Triggers to Prevent Elopement and Behaviors. The importance of immediately completing the admission assessment/evaluation and exit seeking tool. Identifying exit seeking/elopement risk for all new admission/re-admission and utilizing a wander guard device if the person is identified as an elopement risk and what to o or response to a missing/unaccounted for resident/patient as per community process. Record review of in services revealed NAIT L was in serviced on 10/14/23 over Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol. NAIT L was interviewed on 10/16/23 at 9:52 am and was aware of search protocols, missing person/elopement response and procedures, how to identify and respond to triggers and exit seeking behaviors and how to prevent elopement. Who to report to and where to document identified behaviors. NAIT L was able to define abuse and neglect, she gave examples of abuse and neglect, and aware of signs to identify abuse and neglect, NAIT L was aware of what to do when abuse and neglect was suspected and who to report to. A total of 47 staff members were interviewed on 10/15/23 and 10/16/23 across 3 separate shifts, from 6am-2pm, 2pm-10pm and 10pm-6am. Interviewed staff included both direct care and non-direct care staff. Al staff member stated they had recently been trained over elopement, behaviors, exit seeking, facility procedures and abuse and neglect. Nurses were aware of identifying exit seeking behaviors and elopement risks and with all new residents and utilizing a wander guard if resident was an elopement risk. Nurses were also aware of how to respond when a resident is missing and search procedures to follow and initiate. All staff members interview were aware of search protocols were aware of missing person and elopement response and procedures, how to identify and respond to triggers and exit seeking behaviors and how to prevent elopement. Who to report to and where to document identified behaviors. Staff were able to define abuse and neglect, staff gave examples of abuse and neglect, identify abuse and neglect, staff were aware of what to do when abuse and neglect was suspected and who to report to. During an interview with the Medical Director on 10/16/23 at 4:13pm he stated he was a part of a meeting over the weekend (10/14/23-10/15/23) with the facility that covered elopement, door alarms, strategies to monitor the doors, monitoring patients, behaviors and training of the staff to be aware and facility procedures. An IJ was identified on 10/13/23. The IJ template was provided to the facility on [DATE] at 3:53pm. While the IJ was [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that 1 (R#1) of 30 residents with diagnoses of diabetes reviewed for professional standards, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. During R #1's admission medication reconciliation process and throughout his stay, the facility failed to attempt to attain an order for blood glucose monitoring, despite his daily administration of three different diabetic oral medications and decreased appetite. R #1 became lethargic with an altered mental status on 08/31/23 at approximately 7:30 AM until he was transferred to the hospital at 3:42 PM without appropriate physician intervention. R #1 was admitted to the intensive care unit of the hospital with a blood glucose level of 1160 mg/dL (normal reference range 70-100), required an IV mediation intervention for his low blood pressure, and positive pressure ventilation to assist with his breathing. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 09/07/23 at 11:00 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure could affect residents who resided in the facility who had Diabetes by causing a decline in their quality of care and quality of life due to the effects of lack of diabetic monitoring and medication administration. The findings included: Record review of R#1's Face Sheet, dated 09/02/2023, documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) with Diabetic Polyneuropathy (simultaneous malfunction of many nerves throughout the body), abnormal weight loss, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and chronic kidney disease (the kidneys are damaged and cannot filter blood as well as they should). Record review of R#1's comprehensive care plan dated 06/05/2023 documented, Focus: I have chronic health conditions & comorbid conditions that have affected my physical function and may further affect my quality of life. Diabetes, Heart disease, Poor Kidney Functioning. Goal: I will be free from complications associated with co-morbid/poor health, medical problems and will maintain quality of life through my next review date. Interventions: administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician, provide care as tolerated and needed, labs as ordered & report abnormal findings to MD as indicated. Record review of R#1's Minimum Data Set assessment dated [DATE] revealed he: -had clear speech -sometimes understood self and sometimes understood others -had a brief interview of mental status score of 0-severly impaired cognition -required extensive assistance with two-person physical assist for bed mobility and transfers. As well as required extensive assistance with one-person assist with dressing and personal hygiene. -had Diabetes Mellitus Record review of R#1's admission medication reconciliation progress note documented by LVN N dated 05/24/2023 revealed, medication reconciliation clarified with MD: - metFORMIN HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for DM - Tradjenta Oral Tablet 5 MG Give 1 tablet by mouth one time a day for DM - Glimepiride Oral Tablet 4 MG Give 1 tablet by mouth two times a day for diabetes. - There were no blood glucose monitoring included in the reconciliation. Record review of R#1's Medication Administration Record dated 08/01/2023-08/31/2023 revealed Start Date:06/29/2023 Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth one time a day related to TYPE 2 diabetes mellitus with diabetic polyneuropathy; state date:05/24/2023 Tradjenta Oral Tablet 5 MG (Linagliptin) Give 1 tablet by mouth one time a day for DM and Glimepiride Oral Tablet 4 MG (Glimepiride) Give 1 tablet by mouth two times a day for diabetes, were administered through August 2023. Record review of R#1's Blood Sugar Summary dated 05/23/2023 20:40 (8:40PM) revealed R#1 had a blood sugar reading of 120 mg/dL (reference: High of 99.0 exceeded) Record review of R#1's laboratory results date collected 05/23/2023, date received in lab 05/24/2023, revealed R#1's glucose result of 99mg/dL (reference range 70-100) and A1C result of 8.3 (reference range: less than 6.0) Record review of progress note dated 05/29/2023 documented by GVN A, revealed .Resident noted eating dinner by himself without any difficulty, notified RP and will continue to monitor. Record review of R#1's laboratory results date collected 08/09/2023, date received in lab 08/09/2023, revealed R#1's glucose result of 226 mg/dL (reference range 70-100) and A1C result of 7.3 (reference range: less than 6.0) Record review of progress note dated 08/11/2023 documented by LVN N, documented, MD reviewed lab results done on 8/9/23. no new orders given. RP made aware. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented the change in condition reported on this CIC Evaluation are/were: Other change in condition at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 121/79 - 8/31/2023 17:14 - Pulse: P 64 - 8/31/2023 11:14 Pulse Type: Regular - RR: R 18.0 - 7/11/2023 19:50 - Temp: T 97.8 - 7/12/2023 13:07 - Weight: W 153.0 lb - 8/8/2023 13:53 - Pulse Oximetry: O2 100.0 % - 7/12/2023 13:07Method: Room Air - Blood Glucose: BS 120.0 - 5/23/2023 20:40 Relevant medical history is: Dementia Diabetes Chronic Renal Failure/ESRD Code Status: DNR Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Telemed Appointment scheduled for the 9/1/23 between 8-12noon to speak to MD NP. - There was no current blood glucose level documented on the evaluation. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented, While SN was passing out medications CNA informed SN that resident does not want to eat breakfast, SN asked if he ate yesterday but was told he did not. Assess, resident is alert, but does not follow command or oriented.SN noticed resident was lethargic but will resist to touch. BP 121/73, HR 79, R 18, T 97.8 and high blood glucose. Lung's sound clear, abdomen soft and non-tender. Called MD office and spoke to medical assistance who schedule a telemed appointment for tomorrow 8/31/23 between 8 and 12 noon for patient to visit MD nurse practitioner. Per RP, resident should be sent to the hospital for further evaluation. Report given to incoming nurse. Record review of R#1's progress notes dated 08/31/2023 at 15:42 (3:42PM), documented by LVN A, revealed Res. picked up by [ambulance company] going to [hospital]. accompanied by family member. Vital signs as follows: BP 121/98 P75 R 18 Temp. 97.6 BS 'HI. MD: DON notified. Record review of emergency room documentation dated on 08/31/2023 revealed, critical condition(s) addressed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, DKA, and diagnosis' Hypernatremia, Acute kidney injury superimposed on chronic kidney disease, Altered mental, Constipation, Hyperkalemia, Septic shock, DKA (diabetic ketoacidosis). Record review of hospital attending physician's progress note dated 09/02/2023 revealed, R#1 was brought into the emergency department at [NAME] Medical Center on August 31, 2023, in the evening at 6 p.m., sent from the nursing home with report of the patient with altered mental status and high glucose level. Bedside glucometer unable to register the patient's glucose level. On initial presentation to the emergency department, the patient was found to be hypotensive, blood pressure was 80/39. He was severely hyperglycemic, glucose of 1160 with altered mental status. Ketone was positive. The patient initially was admitted with diagnosis of DKA, started on DKA protocol. History according to the wife and the daughter, over the last week prior to this presentation, the patient's mental status has decreased. He was lethargic, less interactive with decreased oral intake. Over the last 3 days, the patient with apparently no oral intake of fluid or food, became nonverbal. On day of presentation, he was unresponsive, delirious, and agitated, brought into the emergency department via ambulance. During an observation on 09/03/2023 at 10:26 AM R#1 was in the ICU, R#1 was in bed, with different fluids running. R#1 had lactated ringer running at 125mL/HR and was also on blood pressure medication assistance Levophed drip. R#1 also had tube feedings running through a nasogastric tube and was on BiPap respiratory support with setting: rate: 20 breath per minute, oxygen:40%. R#1 opened his eyes when ICU Nurse was notifying him that she and her aide were going to turn R#1. Attempted interview with R#1 but did not respond to questions. During an interview on 09/02/2023 at 2:32 PM with the DON, the DON stated if there were a change of condition nurses are expected to perform an assessment and notify physician. The DON stated the expectation of the facility was if any CNAs noticed any change with residents, they would notify the nurse. The DON stated on 08/31/2023 the DON performed an assessment on R#1 and stated vitals were stable, R#1 presented with Altered Mental Status and lethargy. The DON stated the PCP was notified, and stated the facility was told that the PCP's office would schedule tele-med appointment the following day 09/01/2023. The DON stated during her assessment on 08/31/2023, R#1's breathing pattern were stable, and concluded there was not a sense of urgency that warranted an immediate need to send to out to hospital. The DON stated at the request of R#1's spouse, the spouse did not want to wait for the PCP's tele-med appointment that was scheduled for 09/01/23 the following day. The DON stated there were several attempts to call doctor, she stated they called earlier that day of 08/31/2023 and again during lunch on the same day. The DON stated the family initially wanted to send R#1 to the PCP's office, then changed their mind to transfer R#1 to ER due to not wanting to wait till the following day 09/01/2023. The DON determined that there was no need for an immediate need to call 9-1-1 or emergent services but stated something did need to be done for R#1. When asked about the process for medication reconciliation upon admission, the DON stated the admitting nurse will submit referral to the PCP's office, and the PCP's office will either continue home/hospital medications or discontinue medications, it is at the discretion of the physician. The DON stated, when asked about R#1's labs that were taken on 8/9/2023 that resulted a glucose value of 226mg/dL (reference range 70-100), she stated the value was high, and would require insulin in her professional opinion. The DON stated she did not know the blood glucose laboratory results were 226mg/dL and in this case should have inquired to see if physician would give order for glucose checks daily. The DON stated there was no reason why he shouldn't have glucose monitoring and theorized that the staff may have been focused on critical values. The DON stated in her professional opinion accu checks (blood glucose monitoring) would be warranted for R#1 due to him taking three anti-diabetic medications. During the interview with the DON, we both concurrently were looking at progress notes, and the DON stated she could not find any progress note that documented an inquiry to the PCP for R#1 to have accu checks. When asked why the facility did not inquire about accu checks, the DON stated the clinical staff follow physician's orders. The DON stated whenever the facility sends out residents during discharges and transfers, as part of the discharge process the facility will perform an accu check and upon R#1's discharge to hospital the glucose monitor read high on 08/31/2023. The DON stated R#1 had a rapid decline and was hospitalized on [DATE]. During an interview on 09/02/2023 at 3:34PM, CNA A stated on Wednesday 08/23/2023 R#1 was bathed in the morning and did not see anything out of ordinary. CNA A stated she noticed a difference in R#1's demeanor and worked with R#1 from 08/24-08/27. CNA A stated on Wednesday 8/30 upon her return to work, she assisted R#1 to eat but saw a difference in eating and demeanor. CNA A stated R#1 was no longer able to hold cutlery or feed self effectively and notified LVN A on 08/30/2023. During an interview on 09/02/2023 at 4:24PM, LVN A stated she took care of R#1 on 08/23 during her 2-10shift. LVN A stated she did not interact with resident for that long when she admitted him to the LTC side on 08/23/23 and when vitals were okay, she left R#1 and attended other patients. LVN A stated she remembers R#1 was non-verbal and stated the only time she knew R#1 was diabetic, was when R#1 left to the hospital on 8/31, and as a discharge practice, the glucose was checked. She stated R#1 did not show signs of hypo/hyper glycemic symptoms on 08/31 upon leaving to hospital. LVN A stated he looked fine on 08/31/23. LVN A stated R#1 was moved to unit on 08/23/23 and was her patient from 08/24-31 and as part of her job was to take care of her residents. LVN A Stated she did not check blood sugar because there was no order from the physician to do and did not inquire to doctor's office for blood sugar reading due to R#1's appearance of looking fine. LVN A stated she was not made aware of R#1 not eating. During an interview on 09/03/2023 at 5:31 PM with LVN D, LVN D stated on 08/31/2023, a CNA notified her that R#1 did not want to eat, and went into R#1's room, assessed R#1, and stated R#1 exhibited signs of lethargy, but would open eyes then close eyes. LVN D stated R#1, during her assessment, R#1 seemed like he was trying to say something, and when she attempted to touch R#1 to arouse resident, he resisted a little bit, then attempted to give juice to R#1 and tolerated a small amount of fluid well. LVN D stated she attempted more than five times on 08/31/23, to speak to the PCP's office, and stated she does not remember at what time she got a hold of the PCP's office. LVN D stated when she did speak to the PCP's office on 08/31/23, LVN D spoke with the PCP's medical assistant, and notified the medical assistant, of R#1's lethargy but normal vital signs, to which the medical assistant told LVN D, she would notify the doctor, but that she was going to schedule a tele-med appointment for the following day 09/01/23, with the Nurse Practitioner. LVN D said she did not request to immediately speak to the physician after she was given the telemed appointment. LVN D stated, during her conversation with the medical assistant on 08/31/2023 she told the medical assistant vital signs and was aware that he was a diabetic patient. LVN D stated she sometimes can check medical history but did not look at R#1's medical history because it was too early in the morning and worked the 6am-2pm shift on 08/31/2023. LVN D stated, when she was speaking with the PCPs office, she attempted to advocate for resident to either get labs, and requested for anything from the PCP's office. LVN D stated she does not know if doctor called back, stated she gave report to the incoming nurse (2pm-10pm). LVN D stated an accu check (glucose monitoring) would have been beneficial to perform to see if resident was hypoglycemic/hyperglycemic but reiterated vitals were stable and did not check blood glucose or request an order to check the blood glucose level. LVN D stated the family member of R#1 entered R#1's room in the morning after breakfast, R#1 did not eat, but would drink a little fluid. LVN D stated the family member expressed concern of R#1's lethargic state, to which LVN D stated, she told the family member she called the PCP's office, and was waiting for doctor to get back to LVN D. LVN D stated the family member of R#1 advocated for resident to be sent to hospital. LVN D stated she notified the DON and proceeded to call for an ambulance. LVN D stated she would need a physician's order to send out to hospital. LVN D stated after family member's insistence R#1 was sent to the hospital, LVN D stated she called doctor's office and notified the doctor's office that they were sending R#1 to the hospital, due to the family member asking, and sent R#1 to hospital. LVN D stated the situation with R#1 was her first urgent situation, and stated she was nervous, but that the NF gave her education on how to proceed with a change in condition, notify DON, and RP. LVN D stated she was aware that a medical assistant was not a physician or physician representative that could provide orders or conduct assessments. R #1 continued with a symptom of lethargy, not within his normalcy, for an entire first shift and entering the second shift, without physician awareness and assessment until he was sent to the hospital on [DATE] after 3:00 PM During an interview on 09/04/2023 at 12:08 PM with LVN N, LVN N stated he was made aware by the facility of the reasoning for this interview regarding R#1. LVN N stated he knew R#1 for a while and was R#1's admitting nurse. LVN Nstated the process for medication reconciliation was to fax the medication list that residents enter the facility with, either medications they take at home or medication that are sent with residents from the hospital. LVN N stated once the medication list is faxed, he will follow up and call the PCP's office to go over each medication on the medication reconciliation form and would be given instructions to either continue with the medication regimen the residents enter the facility with or to discontinue regimen. The LVN N stated he knew to call the doctor's office when he needed orders and would call sometimes for emergency orders. LVN N stated he did go over R#1's medications, which did include diabetic medications, and when speaking to the PCP's office, he was instructed to continue with R#1's current medication regimen, including the diabetic medications, and did not receive an order for glucose monitoring and did not ask for glucose monitoring. When LVN N was asked why he did not ask for a glucose monitoring order for R#1, LVN N stated he follows physician orders. LVN N stated he does take care of residents that are diabetic. LVN N stated when he is taking care of residents that are diabetic, he does look for blood sugar monitoring order and diabetic medications. LVN N stated, when asked why he did not inquire about glucose monitoring for R#1, who was taking diabetic medications, he stated he follows doctor's order and will only check blood sugars with residents are on insulin. During an interview on 09/03/2023 at 10:26AM with the ICU Nurse, stated R#1 was admitted on [DATE] into the Emergency Department at the local hospital. ICU nurse stated R#1 was admitted for Diabetic Ketoacidosis, Hyperglycemia, Septic Shock and Acute Kidney Failure. The ICU nurse stated R#1's admitting glucose reading was 1160mg/dL. The ICU Nurse stated R#1 received an xray with findings that showed moderately size Right Lower Lobe Infiltrate (a substance denser than air, such as pus, blood, or protein, which lingers within the lungs), the ICU Nurse stated it could be fluid/pneumonia but could not definitively state what the infiltrate was. Currently, R#1 is on blood pressure support, and has begun to open eyes and was showing attempts of spontaneous responses. ICU Nurse stated upon R#1's admission, R#1's labs on 08/31/23 value for ketones were a moderate amount. ICU Nurse stated the amount of ketones in circulation could potentially have come from body not receiving adequate nutrition, and in response R#1's body could have begun metabolizing R#1's musculature. The ICU Nurse stated, the Nutritionist/Dietician documented that R#1 met the criteria of severe protein/calorie malnutrition. The ICU Nurse stated upon admission to the hospital, R#1 was not cognitively aware. During an interview on 09/03/2023 at 2:31PM with the Hospital Attending Physician (HAP), he stated R#1 was sent to the hospital due to R#1 being unresponsive and sugar was over 1000. The HAP stated DKA was very serious, and potentially could have led to death. The HAP stated DKA occurs when there is a high amount of sugar and acid in the body's system. The HAP stated R#1's DKA could have potentially been prevented. The HAP stated as a basic preventative measure for people with diabetes would be to monitor blood sugar and treat with diabetic medications. The HAP stated DKA could potentially affect vital organs and could have led to R#1's Acute Renal Failure on top of R#1's Chronic Kidney Failure. During an interview on 09/03/2023 at 3:22PM the primary care physician (PCP) stated, when a resident is admitted into the nursing facility, the nurses will submit medication reconciliation to doctors' office, and over the phone he will either continue or stop medications. For any additional orders the NF will call his office and notify via phone. The PCP stated he does not know why R#1 was not on glucose monitoring. The PCP stated he knew the resident forever and stated the facility may have called or not for order, but could not recollect, stated he has over 100 patients, and would expect if R#1 was on Diabetes Mellitus (DM) medications, the facility would inquire for glucose monitoring. The PCP stated R#1 has not been a long time diabetic and the lack of glucose monitoring was an oversight on his part. The PCP stated that he expected, as a collaborative effort with the clinical staff at the Nursing Facility (NF), if they see a need for a specific order, whether that's glucose monitoring or diabetic diet, to inquire about and notify him. The PCP stated he expected for the NF to advocate for the safety of all residents. The PCP stated he could not explain why R#1 was not on blood glucose monitoring, due to R#1 taking three DM medications and not on glucose checks, he stated it is a standard of care. The PCP stated if he was made aware of R#1 not having glucose checks, he would have ordered glucose checks for R#1. The PCP stated glucose checks were not only a routine of care but basic standard of care. The PCP stated his expectation of the NF would be to be proactive for patients and advocates for all residents' standard of care. The PCP stated not ordering glucose monitoring was an oversight and takes full responsibility. The PCP stated if R#1's glucose was not monitored, and R#1 was not eating, R#1 could become hypoglycemic which is severe. The PCP stated R#1 could have become too high, an incident like this (DKA) something could raise to an ungodly (critical) amount. The PCP stated he was first notified of R#1's current hospitalization on 09/02/2023. The PCP stated he does not recollect being notified about R#1's transfer to the hospital until 09/02/2023. The PCP stated 1160 blood glucose is absolutely a critical number. The PCP stated there must have been something inciting the incident either a UTI or Pneumonia, something triggered the high sugar. The PCP stated he does not recall being notified of R#1's lethargy or unconsciousness prior to R#1's hospitalization. The PCP stated the NF should have been monitoring glucose. Record review of the facility's Diabetes Management plan date implemented 03/12/19 and date reviewed/revised: January 2023, stated: Purpose: Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Assessment: The interdisciplinary team assesses the diabetic resident/patient upon admission, validates the orders with the attending physician and initiates plan of care that may include: Blood glucose monitoring as ordered Preventative care measures as appropriate Routine care: Blood glucose measurements shall be taken per the physician order. Results outside of ordered parameters should be communicated to the physician per orders 2.For acute events, the clinical record shall include the following information: .Blood glucose test levels . Notification of physician and any new orders. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 09/06/23 at 12:08 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Plan of Removal Immediate Jeopardy Commenced on: 9/4/2023 Situation: Resident # 1 noted with a diagnosis of Type 2 Diabetes Mellitus experienced an acute change in his condition on 8/31/23. The nurse evaluated the patient's condition, identified that he was presenting with s/s altered mental status. The nurse identified as Nurse B, checked Resident's #1 blood glucose level, the meter indicated that the reading was hi. Outcome: On 8/31/23 Nurse B then notified the physician's office of the hi blood glucose reading. Nurse B completed a change in condition SBAR and progress note describing the evaluation findings, physician's recommendations and notifications. [The physician] recommended a telehealth visit for the following day. However, the [family member] wanted the patient to be seen by physician at his office that same day. Since patient did not have an appointment, DON informed [family member] that she could send patient to the ER to which the [family member] agreed. Nurse B immediately sent Resident #1 to the emergency room for evaluation and treatment on 8/31/23. Resident #1 was admitted to the hospital and remains at the hospital. The Director of Nursing Services/Assistant Director of Nursing conducted re-education for the nurse identified as Nurse A regarding reviewing patient's plan of care to include physician's orders and care plan as well as diagnosis in order to identify diabetic patients under the nurse's care. Date commenced: 9/4/23 Date to be completion: 9/5/23 Director of Nursing / Assistant Director of Nursing conducted in-service training for the identified nurse (Nurse B) regarding the expected management of a diabetic patient, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date to be completion: 9/5/23 Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date of completion: 9/4/23 Risk Response: Residents who are diabetic and who are managed by oral medications without routine blood glucose monitoring efforts may potentially be affected by the deficient practice. Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, conducting follow up evaluation of a resident's condition upon reports of a change of condition or status by a C.N.A., proceeding with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date Commenced: 9/4/23 Date to be completion: 9/5/23 The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of orders. The nurse will update the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 9/4/23 Date to be completion: 9/5/23 Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date: 9/4/2023 Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, fol[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician supervised the care of a resident for one (Resident #1) of five residents reviewed for physician services. The facility failed to ensure the physician supervised and monitored Resident #1's blood glucose monitoring since Resident #1 was diagnosed with diabetes and was prescribed and administered three different oral diabetic medications. R #1 became lethargic with an altered mental status on 08/31/23 at approximately 7:30 AM until he was transferred to the hospital at 3:42 PM without any appropriate physician intervention. R #1 was admitted to the intensive care unit of the hospital with a blood glucose level of 1160 mg/dL (normal reference range 70-100), required an IV medication intervention for his low blood pressure, and positive pressure ventilation to assist with his breathing. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 09/07/23 at 11:00 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition or illness up to and including death. The findings included: Record review of R#1's Face Sheet, dated 09/02/2023, documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) with Diabetic Polyneuropathy (simultaneous malfunction of many nerves throughout the body), abnormal weight loss, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and chronic kidney disease (the kidneys are damaged and cannot filter blood as well as they should). Record review of R#1's comprehensive care plan dated 06/05/2023 documented, Focus: I have chronic health conditions & comorbid conditions that have affected my physical function and may further affect my quality of life. Diabetes, Heart disease, Poor Kidney Functioning. Goal: I will be free from complications associated with co-morbid/poor health, medical problems and will maintain quality of life through my next review date. Interventions: administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician, provide care as tolerated and needed, labs as ordered & report abnormal findings to MD as indicated. Record review of R#1's Minimum Data Set assessment dated [DATE] revealed he: -had clear speech -sometimes understood self and sometimes understood others -had a brief interview of mental status score of 0-severly impaired cognition -required extensive assistance with two-person physical assist for bed mobility and transfers. As well as required extensive assistance with one-person assist with dressing and personal hygiene. -had Diabetes Mellitus Record review of R#1's admission medication reconciliation progress note documented by LVN N dated 05/24/2023 revealed, medication reconciliation clarified with MD: - metFORMIN HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for DM - Tradjenta Oral Tablet 5 MG Give 1 tablet by mouth one time a day for DM - Glimepiride Oral Tablet 4 MG Give 1 tablet by mouth two times a day for diabetes. - There was no blood glucose monitoring included in the reconciliation. Record review of R#1's Blood Sugar Summary dated 05/23/2023 at 20:40 (8:40PM) revealed R#1 had a blood sugar reading of 120 mg/dL (reference: High of 99.0 exceeded) Record review of R#1's laboratory results date collected 05/23/2023, date received in lab 05/24/2023, revealed R#1's glucose result of 99mg/dL (reference range 70-100) and A1C result of 8.3 (reference range: less than 6.0) Record review of R#1's laboratory results date collected 08/09/2023, date received in lab 08/09/2023, revealed R#1's glucose result of 226mg/dL (reference range 70-100) and A1C result of 7.3 (reference range: less than 6.0) Record review of R#1's progress note dated 08/11/2023 documented by LVN N, documented, MD reviewed lab results done on 8/9/23. no new orders given. RP made aware. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented the change in condition reported on this CIC Evaluation are/were: Other change in condition at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 121/79 - 8/31/2023 17:14 - Pulse: P 64 - 8/31/2023 11:14 Pulse Type: Regular - RR: R 18.0 - 7/11/2023 19:50 - Temp: T 97.8 - 7/12/2023 13:07 - Weight: W 153.0 lb - 8/8/2023 13:53 - Pulse Oximetry: O2 100.0 % - 7/12/2023 13:07Method: Room Air - Blood Glucose: BS 120.0 - 5/23/2023 20:40 Relevant medical history is: Dementia Diabetes Chronic Renal Failure/ESRD Code Status: DNR Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Telemed Appointment scheduled for the 9/1/23 between 8-12noon to speak to MD NP. - There was no current blood glucose level documented on the evaluation. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented, While SN was passing out medications CNA informed SN that resident does not want to eat breakfast, SN asked if he ate yesterday but was told he did not. Assess, resident is alert, but does not follow command or oriented.SN noticed resident was lethargic but will resist to touch. BP 121/73, HR 79, R 18, T 97.8 and high blood glucose. Lung's sound clear, abdomen soft and non-tender. Called MD office and spoke to medical assistance who schedule a telemed appointment for tomorrow 8/31/23 between 8 and 12 noon for patient to visit MD nurse practitioner. Per RP, resident should be sent to the hospital for further evaluation. Report given to incoming nurse. Record review of R#1's progress notes dated 08/31/2023 at 15:42 (3:42PM), documented by LVN A, revealed Res. picked up by [ambulance company] going to [hospital]. accompanied by family member. Vital signs as follows: BP 121/98 P75 R 18 Temp. 97.6 BS 'HI. MD: DON notified. Record review of R#1's emergency room documentation dated on 08/31/2023 revealed, critical condition(s) addressed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, DKA, and diagnosis' Hypernatremia, Acute kidney injury superimposed on chronic kidney disease, Altered mental, Constipation, Hyperkalemia, Septic shock, DKA (diabetic ketoacidosis). Record review of hospital attending physician's progress note dated 09/02/2023 revealed, R#1 was brought into the emergency department at [hospital] on August 31, 2023, in the evening at 6 p.m., sent from the nursing home with report of the patient with altered mental status and high glucose level. Bedside glucometer unable to register the patient's glucose level. On initial presentation to the emergency department, the patient was found to be hypotensive, blood pressure was 80/39. He was severely hyperglycemic, glucose of 1160 with altered mental status. Ketone was positive. The patient initially was admitted with diagnosis of DKA, started on DKA protocol. History according to the [family members] , over the last week prior to this presentation, the patient's mental status has decreased. He was lethargic, less interactive with decreased oral intake. Over the last 3 days, the patient with apparently no oral intake of fluid or food, became nonverbal. On day of presentation, he was unresponsive, delirious, and agitated, brought into the emergency department via ambulance. During an observation and attempted interview on 09/03/2023 at 10:26 AM R#1 was in the ICU, R#1 was in bed, with different fluids running. R#1 had lactated ringer running at 125mL/HR and was also on blood pressure medication assistance Levophed (used for severe low blood pressure , shock, or low heart rate) drip. R#1 also had tube feedings running through a nasogastric tube and was on BiPap respiratory support with setting: rate: 20 breath per minute, oxygen:40%. R#1 opened his eyes when ICU Nurse was notifying him that she and her aide were going to turn R#1. Attempted interview with R#1 but did not respond to questions. During an interview and record review on 09/02/2023 at 2:32 PM with the DON, the DON stated if there were a change of condition nurses are expected to perform an assessment and notify physician. The DON stated the expectation of the facility was if any CNAs noticed any change with residents, they would notify the nurse. The DON stated on 08/31/2023 the DON performed an assessment on R#1 and stated vitals were stable, R#1 presented with Altered Mental Status and lethargy. The DON stated the PCP was notified, and stated the facility was told that the PCP's office would schedule tele-med appointment the following day 09/01/2023. The DON stated during her assessment on 08/31/2023, R#1's breathing pattern were stable, and concluded there was not a sense of urgency that warranted an immediate need to send to out to hospital. The DON stated at the request of R#1's family member, the family member did not want to wait for the PCP's tele-med appointment that was scheduled for 09/01/23 the following day. The DON stated there were several attempts to call doctor, she stated they called earlier that day of 08/31/2023 and again during lunch on the same day. The DON stated the family initially wanted to send R#1 to the PCP's office, then changed their mind to transfer R#1 to ER due to not wanting to wait until the following day 09/01/2023. The DON determined that there was no need for an immediate need to call 9-1-1 or emergent services but stated something did need to be done for R#1. When asked about the process for medication reconciliation upon admission, the DON stated the admitting nurse will submit referral to the PCP's office, and the PCP's office will either continue home/hospital medications or discontinue medications, it is at the discretion of the physician. The DON stated, when asked about R#1's labs that were taken on 8/9/2023 that resulted a glucose value of 226mg/dL (reference range 70-100), she stated the value was high, and would require insulin in her professional opinion. The DON stated she did not know the blood glucose laboratory results were 226mg/dL and in this case should have inquired to see if physician would give order for glucose checks daily. The DON stated there was no reason why he shouldn't have glucose monitoring and theorized that the staff may have been focused on critical values. The DON stated in her professional opinion accu checks (blood glucose monitoring) would be warranted for R#1 due to him taking three anti-diabetic medications. During the interview with the DON, progress notes were reviewed, and the DON stated she could not find any progress note that documented an inquiry to the PCP for R#1 to have accu checks. When asked why the facility did not inquire about accu checks, the DON stated the clinical staff follow physician's orders. The DON stated whenever the facility sends out residents during discharges and transfers, as part of the discharge process the facility will perform an accu check and upon R#1's discharge to hospital the glucose monitor read high on 08/31/2023. The DON stated R#1 had a rapid decline and was hospitalized on [DATE]. During an interview on 09/03/2023 at 5:31 PM with LVN D, LVN D stated on 08/31/2023, a CNA notified her that R#1 did not want to eat, and went into R#1's room, assessed R#1, and stated R#1 exhibited signs of lethargy, but would open eyes then close eyes. LVN D stated R#1, during her assessment, R#1 seemed like he was trying to say something, and when she attempted to touch R#1 to arouse resident, he resisted a little bit, then attempted to give juice to R#1 and tolerated a small amount of fluid well. LVN D stated she attempted more than five times on 08/31/23, to speak to the PCP's office, and stated she does not remember at what time she got a hold of the PCP's office. LVN D stated when she did speak to the PCP's office on 08/31/23, LVN D spoke with the PCP's medical assistant, and notified the medical assistant, of R#1's lethargy but normal vital signs, to which the medical assistant told LVN D, she would notify the doctor, but that she was going to schedule a tele-med appointment for the following day 09/01/23, with the Nurse Practitioner. LVN D said she did not request to immediately speak to the physician after she was given the telemed appointment. LVN D stated, during her conversation with the medical assistant on 08/31/2023 she told the medical assistant vital signs and was aware that he was a diabetic patient. LVN D stated she sometimes can check medical history but did not look at R#1's medical history because it was too early in the morning and worked the 6am-2pm shift on 08/31/2023. LVN D stated, when she was speaking with the PCPs office, she attempted to advocate for resident to either get labs, and requested for anything from the PCP's office. LVN D stated she does not know if doctor called back, stated she gave report to the incoming nurse (2-10pm). LVN D stated an accu check (glucose monitoring) would have been beneficial to perform to see if resident was hypoglycemic/hyperglycemic but reiterated vitals were stable and did not check blood glucose or request an order to check the blood glucose level. LVN D stated the family member of R#1 entered R#1's room in the morning after breakfast, R#1 did not eat, but would drink a little fluid. LVN D stated the family member expressed concern of R#1's lethargic state, to which LVN D stated, she told the family member she called the PCP's office, and was waiting for doctor to get back to LVN D. LVN D stated the family member of R#1 advocated for resident to be sent to hospital. LVN D stated she notified the DON and proceeded to call for an ambulance. LVN D stated she would need a physician's order to send out to hospital. LVN D stated after family member's insistence R#1 was sent to the hospital, LVN D stated she called doctor's office and notified the doctor's office that they were sending R#1 to the hospital, due to the family member asking, and sent R#1 to hospital. LVN D stated the situation with R#1 was her first urgent situation, and stated she was nervous, but that the NF gave her education on how to proceed with a change in condition, notify DON, and RP. LVN D stated she was aware that a medical assistant was not a physician or physician representative that could provide orders or conduct assessments. R #1 continued with a symptom of lethargy, not within his normalcy, for an entire first shift and entering the second shift, without physician awareness and assessment until he was sent to the hospital on [DATE] after 3:00 PM During an interview on 09/04/2023 at 12:08 PM with LVN N, LVN N stated he was made aware by the facility of the reasoning for this interview regarding R#1. LVN N stated he knew R#1 for a while and was R#1's admitting nurse. LVN Nstated the process for medication reconciliation was to fax the medication list that residents enter the facility with, either medications they take at home or medication that are sent with residents from the hospital. LVN N stated once the medication list is faxed, he will follow up and call the PCP's office to go over each medication on the medication reconciliation form and would be given instructions to either continue with the medication regimen the residents enter the facility with or to discontinue regimen. The LVN N stated he knew to call the doctor's office when he needed orders and would call sometimes for emergency orders. LVN N stated he did go over R#1's medications, which did include diabetic medications, and when speaking to the PCP's office, he was instructed to continue with R#1's current medication regimen, including the diabetic medications, and did not receive an order for glucose monitoring and did not ask for glucose monitoring. When LVN N was asked why he did not ask for a glucose monitoring order for R#1, LVN N stated he follows physician orders. LVN N stated he does take care of residents that are diabetic. LVN N stated when he is taking care of residents that are diabetic, he does look for blood sugar monitoring order and diabetic medications. LVN N stated, when asked why he did not inquire about glucose monitoring for R#1, who was taking diabetic medications, he stated he follows doctor's order and will only check blood sugars with residents are on insulin. During an interview on 09/03/2023 at 3:22PM the primary care physician (PCP) stated, when a resident is admitted into the nursing facility, the nurses will submit medication reconciliation to doctors' office, and over the phone he will either continue or stop medications. For any additional orders the NF will call his office and notify via phone. The PCP stated he does not know why R#1 was not on glucose monitoring. The PCP stated he knew the resident forever and stated the facility may have called or not for order, but could not recollect, stated he has over 100 patients, and would expect if R#1 was on Diabetes Mellitus (DM) medications, the facility would inquire for glucose monitoring. The PCP stated R#1 has not been a long time diabetic and the lack of glucose monitoring was an oversight on his part. The PCP stated that he expected, as a collaborative effort with the clinical staff at the Nursing Facility (NF), if they see a need for a specific order, whether that's glucose monitoring or diabetic diet, to inquire about and notify him. The PCP stated he expected for the NF to advocate for the safety of all residents. The PCP stated he could not explain why R#1 was not on blood glucose monitoring, due to R#1 taking three DM medications and not on glucose checks, he stated it is a standard of care. The PCP stated if he was made aware of R#1 not having glucose checks, he would have ordered glucose checks for R#1. The PCP stated glucose checks were not only a routine of care but basic standard of care. The PCP stated his expectation of the NF would be to be proactive for patients and advocates for all residents' standard of care. The PCP stated not ordering glucose monitoring was an oversight and takes full responsibility. The PCP stated if R#1's glucose was not monitored, and R#1 was not eating, R#1 could become hypoglycemic which is severe. The PCP stated R#1 could have become too high, an incident like this (DKA) something could raise to an ungodly (critical) amount. The PCP stated he was first notified of R#1's current hospitalization on 09/02/2023. The PCP stated he does not recollect being notified about R#1's transfer to the hospital until 09/02/2023. The PCP stated 1160 blood glucose is absolutely a critical number. The PCP stated there must have been something inciting the incident either a UTI or Pneumonia, something triggered the high sugar. The PCP stated he does not recall being notified of R#1's lethargy or unconsciousness prior to R#1's hospitalization. The PCP stated the NF should have been monitoring glucose. Record review of the facility's Changes in Resident Condition Policy date implemented 05/2017 and date reviewed/revised January 2023 stated: 1. The resident, attending physician and resident representative or designated family member should be notified when there is: c. a significant change in the resident's physical, mental or psychosocial status. 2. Provide assessment information to physician d. a need to alter treatment significantly (i.e., a need form of treatment due to adverse consequences, or to commence a new for of treatment); e. A decision to transfer the resident from the community, g. when laboratory, radiology or other diagnostic results fall outside the clinical reference ranges set by the contracted service provider or per physician orders Record review of the facility's Diabetes Management date implemented 03/12/19 and date reviewed/revised: January 2023, stated: Purpose: Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Assessment: The interdisciplinary team assesses the diabetic resident/patient upon admission, validates the orders with the attending physician and initiates plan of care that may include: Blood glucose monitoring as ordered Preventative care measures as appropriate Routine care: Blood glucose measurements shall be taken per the physician order. Results outside of ordered parameters should be communicated to the physician per orders 2.For acute events, the clinical record shall include the following information: .Blood glucose test levels . Notification of physician and any new orders. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 09/06/23 at 12:08 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Plan of Removal Immediate Jeopardy Situation: Resident # 1 noted with a diagnosis of Type 2 Diabetes Mellitus experienced an acute change in his condition on 8/31/23. The nurse evaluated the patient's condition, identified that he was presenting with s/s altered mental status. The nurse identified as Nurse B, checked Resident's #1 blood glucose level, the meter indicated that the reading was hi. Outcome: On 8/31/23 Nurse B then notified the physician's office of the hi blood glucose reading. Nurse B completed a change in condition SBAR and progress note describing the evaluation findings, physician's recommendations and notifications. [The physician] recommended a telehealth visit for the following day. However, the [family member] wanted the patient to be seen by physician at his office that same day. Since patient did not have an appointment, DON informed [family member] that she could send patient to the ER to which the [family member] agreed. Nurse B immediately sent Resident #1 to the emergency room for evaluation and treatment on 8/31/23. Resident #1 was admitted to the hospital and remains at the hospital. The Director of Nursing Services/Assistant Director of Nursing conducted re-education for the nurse identified as Nurse A regarding reviewing patient's plan of care to include physician's orders and care plan as well as diagnosis in order to identify diabetic patients under the nurse's care. Date commenced: 9/4/23 Date to be completion: 9/5/23 Director of Nursing / Assistant Director of Nursing conducted in-service training for the identified nurse (Nurse B) regarding the expected management of a diabetic patient, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date to be completion: 9/5/23 Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date of completion: 9/4/23 Risk Response: Residents who are diabetic and who are managed by oral medications without routine blood glucose monitoring efforts may potentially be affected by the deficient practice. Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, conducting follow up evaluation of a resident's condition upon reports of a change of condition or status by a C.N.A., proceeding with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date Commenced: 9/4/23 Date to be completion: 9/5/23 The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of orders. The nurse will update the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 9/4/23 Date to be completion: 9/5/23 Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date: 9/4/2023 Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date Commenced: 9/4/2023 Date to be completion: 9/5/23 All staff will be in-serviced on ANE- Prevention, Identification, Protecting and Reporting. Date Commenced: 9/4/2023 Date to be completion: 9/5/23 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. Monitoring Response: The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine accu-checks monitoring that is prescribed and interview random nurses to review how to identify patients who have diagnosis of diabetes. Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months. The surveyor confirmed the facility's Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy that included: Record review: -Facility staff training on documenting in chart change of condition/observation and monitoring change of condition/reviewing resident care plans and physician's orders. -Audit of facility residents with diabetes type II and confirmation of standing orders -Employee record for completion of training -QAPI record of meeting discussing diabetic management protocol and changes in condition with recommendation to re-educate all licensed nurses in these areas and confirm current orders with physicians. Hospital record documented: R #1's Dx: Hypernatremia, Acute Kidney Injury superimposed on chronic kidney disease, Altered Mental Status, Constipation, hyperkalemia, Sepsis; Septic Shock, Diabetic Ketoacidosis. R #1's H&P: presented with Altered Mental Status, Dry Mucous Membranes, Distended Abdomen V/S @ 8/31/2023 16:09 T 97.3, RR 20, HR 67, B/P 80/39 O2 98% Interviews: -13 interviews were conducted on 9/6/2023 and 9/7/2023 across 3 shifts with LVN A through LVN M to ensure training was completed. Training began after the facility was notified that the plan of corretion was accepted around noon on 9/6/2023, and was finished the same day on 9/6/2023. Responses were consistent facility training and policy. -demonstration of knowledge of documenting in chart change of condition/ observation and monitoring change of condition/reviewing resident care plans and physician's orders. -Interviewed DON on process for m[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (R #1) of four residents that were diagnosed with diabetes mellitus. 1. Multiple nursing personnel who cared for R#1 did not consult with R#1's Physician, in attempt to retrieve instructions for blood glucose monitoring. 2. LVN A cared for R#1 for multiple days and stated she did not know he was a diabetic. 3. DON assessed R#1 on 8/31/23 and despite of his change in condition of lethargy and altered level of consciousness, the DON did not conclude that R#1's change in condition was urgent enough to require emergent medical treatment. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While the IJ was removed on 09/07/23 at 11:00 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure to notify and consult with the physician regarding a change of condition, and diabetic management resulted in a delay of appropriate medical treatment and a worsening of R#1's condition. This failure had the potential to affect residents receiving diabetic management who may experience a significant change in condition and or death. The findings included: Record review of R#1's Face Sheet, dated 09/02/2023, documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) with Diabetic Polyneuropathy (simultaneous malfunction of many nerves throughout the body), abnormal weight loss, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and chronic kidney disease (the kidneys are damaged and cannot filter blood as well as they should). Record review of R#1's comprehensive care plan dated 06/05/2023 documented, Focus: I have chronic health conditions & comorbid conditions that have affected my physical function and may further affect my quality of life. Diabetes, Heart disease, Poor Kidney Functioning. Goal: I will be free from complications associated with co-morbid/poor health, medical problems and will maintain quality of life through my next review date. Interventions: administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician, provide care as tolerated and needed, labs as ordered & report abnormal findings to MD as indicated. Record review of R#1's Minimum Data Set assessment dated [DATE] revealed he: -had clear speech -sometimes understood self and sometimes understood others -had a brief interview of mental status score of 0-severly impaired cognition -required extensive assistance with two-person physical assist for bed mobility and transfers. As well as required extensive assistance with one-person assist with dressing and personal hygiene. -had Diabetes Mellitus Record review of R#1's admission medication reconciliation progress note documented by LVN N dated 05/24/2023 revealed, medication reconciliation clarified with MD: - metFORMIN HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for DM - Tradjenta Oral Tablet 5 MG Give 1 tablet by mouth one time a day for DM - Glimepiride Oral Tablet 4 MG Give 1 tablet by mouth two times a day for diabetes. - There were no blood glucose monitoring included in the reconciliation. Record review of R#1's Medication Administration Record dated 08/01/2023-08/31/2023 revealed Start Date:06/29/2023 Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth one time a day related to TYPE 2 diabetes mellitus with diabetic polyneuropathy; state date:05/24/2023 Tradjenta Oral Tablet 5 MG (Linagliptin) Give 1 tablet by mouth one time a day for DM and Glimepiride Oral Tablet 4 MG (Glimepiride) Give 1 tablet by mouth two times a day for diabetes, were administered through August 2023. Record review of R#1's Blood Sugar Summary dated 05/23/2023 20:40 (8:40PM) revealed R#1 had a blood sugar reading of 120 mg/dL (reference: High of 99.0 exceeded) Record review of R#1's laboratory results date collected 05/23/2023, date received in lab 05/24/2023, revealed R#1's glucose result of 99mg/dL (reference range 70-100) and A1C result of 8.3 (reference range: less than 6.0) Record review of R#1's laboratory results date collected 08/09/2023, date received in lab 08/09/2023, revealed R#1's glucose result of 226mg/dL (reference range 70-100) and A1C result of 7.3 (reference range: less than 6.0) Record review of progress note dated 08/11/2023 documented by LVN N, documented, MD reviewed lab results done on 8/9/23. no new orders given. RP made aware. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented the change in condition reported on this CIC Evaluation are/were: Other change in condition at the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 121/79 - 8/31/2023 17:14 - Pulse: P 64 - 8/31/2023 11:14 Pulse Type: Regular - RR: R 18.0 - 7/11/2023 19:50 - Temp: T 97.8 - 7/12/2023 13:07 - Weight: W 153.0 lb - 8/8/2023 13:53 - Pulse Oximetry: O2 100.0 % - 7/12/2023 13:07Method: Room Air - Blood Glucose: BS 120.0 - 5/23/2023 20:40 Relevant medical history is: Dementia Diabetes Chronic Renal Failure/ESRD Code Status: DNR Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Telemed Appointment scheduled for the 9/1/23 between 8-12noon to speak to MD NP. - There was no current blood glucose level documented on the evaluation. Record review of R#1's progress notes dated 08/31/2023 at 07:30AM documented by LVN D documented, While SN was passing out medications CNA informed SN that resident does not want to eat breakfast, SN asked if he ate yesterday but was told he did not. Assess, resident is alert, but does not follow command or oriented.SN noticed resident was lethargic but will resist to touch. BP 121/73, HR 79, R 18, T 97.8 and high blood glucose. Lung's sound clear, abdomen soft and non-tender. Called MD office and spoke to medical assistance who schedule a telemed appointment for tomorrow 8/31/23 between 8 and 12 noon for patient to visit MD nurse practitioner. Per RP, resident should be sent to the hospital for further evaluation. Report given to incoming nurse. Record review of R#1's progress notes dated 08/31/2023 at 15:42 (3:42PM), documented by LVN A, revealed Res. picked up by [ambulance company] going to [hospital]. accompanied by family member. Vital signs as follows: BP 121/98 P75 R 18 Temp. 97.6 BS 'HI. MD: DON notified. Record review of R#1's emergency room documentation dated on 08/31/2023 revealed, critical condition(s) addressed for impending deterioration include: airway, respiratory, cardiovascular, central nervous system, metabolic, DKA, and diagnosis' Hypernatremia, Acute kidney injury superimposed on chronic kidney disease, Altered mental, Constipation, Hyperkalemia, Septic shock, DKA (diabetic ketoacidosis). Record review of Hospital Attending Physician's progress note dated 09/02/2023 revealed, R#1 was brought into the emergency department at [hospital] on August 31, 2023, in the evening at 6 p.m., sent from the nursing home with report of the patient with altered mental status and high glucose level. Bedside glucometer unable to register the patient's glucose level. On initial presentation to the emergency department, the patient was found to be hypotensive (low blood pressure), blood pressure was 80/39. He was severely hyperglycemic (high blood sugar), glucose of 1160 with altered mental status. Ketone was positive. The patient initially was admitted with diagnosis of DKA, started on DKA protocol. History according to the [family members] , over the last week prior to this presentation, the patient's mental status has decreased. He was lethargic, less interactive with decreased oral intake. Over the last 3 days, the patient with apparently no oral intake of fluid or food, became nonverbal. On day of presentation, he was unresponsive, delirious, and agitated, brought into the emergency department via ambulance. During an observation on 09/03/2023 at 10:26 AM R#1 was in the ICU, R#1 was in bed, with different fluids running. R#1 had lactated ringer running at 125mL/HR and was also on blood pressure medication assistance Levophed drip. R#1 also had tube feedings running through a nasogastric tube and was on BiPap respiratory support with setting: rate: 20 breath per minute, oxygen:40%. R#1 opened his eyes when ICU Nurse was notifying him that she and her aide were going to turn R#1. Attempted interview with R#1 but did not respond to questions. During an interview on 09/02/2023 at 2:32 PM with the DON, the DON stated if there were a change of condition nurses are expected to perform an assessment and notify physician. The DON stated the expectation of the facility was if any CNAs noticed any change with residents, they would notify the nurse. The DON stated on 08/31/2023 the DON performed an assessment on R#1 and stated vitals were stable, R#1 presented with Altered Mental Status and lethargy. The DON stated the PCP was notified, and stated the facility was told that the PCP's office would schedule tele-med appointment the following day 09/01/2023. The DON stated during her assessment on 08/31/2023, R#1's breathing pattern were stable, and concluded there was not a sense of urgency that warranted an immediate need to send to out to hospital. The DON stated at the request of R#1's spouse, the spouse did not want to wait for the PCP's tele-med appointment that was scheduled for 09/01/23 the following day. The DON stated there were several attempts to call doctor, she stated they called earlier that day of 08/31/2023 and again during lunch on the same day. The DON stated the family initially wanted to send R#1 to the PCP's office, then changed their mind to transfer R#1 to ER due to not wanting to wait till the following day 09/01/2023. The DON determined that there was no need for an immediate need to call 9-1-1 or emergent services but stated something did need to be done for R#1. When asked about the process for medication reconciliation upon admission, the DON stated the admitting nurse will submit referral to the PCP's office, and the PCP's office will either continue home/hospital medications or discontinue medications, it is at the discretion of the physician. The DON stated, when asked about R#1's labs that were taken on 8/9/2023 that resulted a glucose value of 226mg/dL (reference range 70-100), she stated the value was high, and would require insulin in her professional opinion. The DON stated she did not know the blood glucose laboratory results were 226mg/dL and in this case should have inquired to see if physician would give order for glucose checks daily. The DON stated there was no reason why he shouldn't have glucose monitoring and theorized that the staff may have been focused on critical values. The DON stated in her professional opinion accu checks (blood glucose monitoring) would be warranted for R#1 due to him taking three anti-diabetic medications. During the interview with the DON, we both concurrently were looking at progress notes, and the DON stated she could not find any progress note that documented an inquiry to the PCP for R#1 to have accu checks. When asked why the facility did not inquire about accu checks, the DON stated the clinical staff follow physician's orders. The DON stated whenever the facility sends out residents during discharges and transfers, as part of the discharge process the facility will perform an accu check and upon R#1's discharge to hospital the glucose monitor read high on 08/31/2023. The DON stated R#1 had a rapid decline and was hospitalized on [DATE]. During an interview on 09/02/2023 at 4:24PM, LVN A stated she took care of R#1 on 08/23 during her 2-10shift. LVN A stated she did not interact with resident for that long when she admitted him to the LTC side on 08/23/23 and when vitals were okay, she left R#1 and attended other patients. LVN A stated she remembers R#1 was non-verbal and stated the only time she knew R#1 was diabetic, was when R#1 left to the hospital on 8/31, and as a discharge practice, the glucose was checked. She stated R#1 did not show signs of hypo/hyper glycemic symptoms on 08/31 upon leaving to hospital. LVN A stated he looked fine on 08/31/23. LVN A stated R#1 was moved to unit on 08/23/23 and was her patient from 08/24-31 and as part of her job was to take care of her residents. LVN A Stated she did not check blood sugar because there was no order from the physician to do and did not inquire to doctor's office for blood sugar reading due to R#1's appearance of looking fine. LVN A stated she was not made aware of R#1 not eating. During an interview on 09/03/2023 at 10:26AM with the ICU Nurse, stated R#1 was admitted on [DATE] into the Emergency Department at [NAME] Medical Centerthe local hospital. ICU nurse stated R#1 was admitted for Diabetic Ketoacidosis, Hyperglycemia, Septic Shock and Acute Kidney Failure. The ICU nurse stated R#1's admitting glucose reading was 1160mg/dL. The ICU Nurse stated R#1 received an xray with findings that showed moderately size Right Lower Lobe Infiltrate (a substance denser than air, such as pus, blood, or protein, which lingers within the lungs) , the ICU Nurse stated it could be fluid/pneumonia but could not definitively state what infiltrate was. Currently, R#1 is on blood pressure support, and has begun to open eyes and was showing attempts of spontaneous responses. ICU Nurse stated upon R#1's admission, R#1's labs on 08/31/23 value for ketones were a moderate amount. ICU Nurse stated the amount of ketones in circulation could potentially have come from body not receiving adequate nutrition, and in response R#1's body could have begun metabolizing R#1's musculature. The ICU Nurse stated, the Nutritionist/Dietician documented that R#1 met the criteria of severe protein/calorie malnutrition. The ICU Nurse stated upon admission to the hospital, R#1 was not cognitively aware During an interview on 09/03/2023 at 5:31 PM with LVN D, LVN D stated on 08/31/2023, a CNA notified her that R#1 did not want to eat, and went into R#1's room, assessed R#1, and stated R#1 exhibited signs of lethargy, but would open eyes then close eyes. LVN D stated R#1, during her assessment, R#1 seemed like he was trying to say something, and when she attempted to touch R#1 to arouse resident, he resisted a little bit, then attempted to give juice to R#1 and tolerated a small amount of fluid well. LVN D stated she attempted more than five times on 08/31/23, to speak to the PCP's office, and stated she does not remember at what time she got a hold of the PCP's office. LVN D stated when she did speak to the PCP's office on 08/31/23, LVN D spoke with the PCP's medical assistant, and notified the medical assistant, of R#1's lethargy but normal vital signs, to which the medical assistant told LVN D, she would notify the doctor, but that she was going to schedule a tele-med appointment for the following day 09/01/23, with the Nurse Practitioner. LVN D said she did not request to immediately speak to the physician after she was given the telemed appointment. LVN D stated, during her conversation with the medical assistant on 08/31/2023 she told the medical assistant vital signs and was aware that he was a diabetic patient. LVN D stated she sometimes can check medical history but did not look at R#1's medical history because it was too early in the morning and worked the 6am-2pm shift on 08/31/2023. LVN D stated, when she was speaking with the PCPs office, she attempted to advocate for resident to either get labs, and requested for anything from the PCP's office. LVN D stated she does not know if doctor called back, stated she gave report to the incoming nurse (2-10pm). LVN D stated an accu check (glucose monitoring) would have been beneficial to perform to see if resident was hypoglycemic/hyperglycemic but reiterated vitals were stable and did not check blood glucose or request an order to check the blood glucose level. LVN D stated the family member of R#1 entered R#1's room in the morning after breakfast, R#1 did not eat, but would drink a little fluid. LVN D stated the family member expressed concern of R#1's lethargic state, to which LVN D stated, she told the family member she called the PCP's office, and was waiting for doctor to get back to LVN D. LVN D stated the family member of R#1 advocated for resident to be sent to hospital. LVN D stated she notified the DON and proceeded to call for an ambulance. LVN D stated she would need a physician's order to send out to hospital. LVN D stated after family member's insistence R#1 was sent to the hospital, LVN D stated she called doctor's office and notified the doctor's office that they were sending R#1 to the hospital, due to the family member asking, and sent R#1 to hospital. LVN D stated the situation with R#1 was her first urgent situation, and stated she was nervous, but that the NF gave her education on how to proceed with a change in condition, notify DON, and RP. LVN D stated she was aware that a medical assistant was not a physician or physician representative that could provide orders or conduct assessments. R #1 continued with a symptom of lethargy, not within his normalcy, for an entire first shift and entering the second shift, without physician awareness and assessment until he was sent to the hospital on [DATE] after 3:00 PM. During an interview on 09/04/2023 at 12:08 PM with LVN N, LVN N stated he was made aware by the facility of the reasoning for this interview regarding R#1. LVN N stated he knew R#1 for a while and was R#1's admitting nurse. LVN Nstated the process for medication reconciliation was to fax the medication list that residents enter the facility with, either medications they take at home or medication that are sent with residents from the hospital. LVN N stated once the medication list is faxed, he will follow up and call the PCP's office to go over each medication on the medication reconciliation form and would be given instructions to either continue with the medication regimen the residents enter the facility with or to discontinue regimen. The LVN N stated he knew to call the doctor's office when he needed orders and would call sometimes for emergency orders. LVN N stated he did go over R#1's medications, which did include diabetic medications, and when speaking to the PCP's office, he was instructed to continue with R#1's current medication regimen, including the diabetic medications, and did not receive an order for glucose monitoring and did not ask for glucose monitoring. When LVN N was asked why he did not ask for a glucose monitoring order for R#1, LVN N stated he follows physician orders. LVN N stated he does take care of residents that are diabetic. LVN N stated when he is taking care of residents that are diabetic, he does look for blood sugar monitoring order and diabetic medications. LVN N stated, when asked why he did not inquire about glucose monitoring for R#1, who was taking diabetic medications, he stated he follows doctor's order and will only check blood sugars with residents are on insulin. During an interview on 09/03/2023 at 2:31PM with the Hospital Attending Physician (HAP), he stated R#1 was sent to the hospital due to R#1 being unresponsive and blood sugar level over 1000. The HAP stated DKA was very serious, and potentially could have led to death. The HAP stated DKA occurs when sugar is high and there is high amount of acid in the body's system. The HAP stated R#1's DKA could have potentially been prevented. The HAP stated as a basic preventative measure for people with diabetes would be to monitor blood sugar and treat with diabetic medications. The HAP stated DKA could potentially affect vital organs and could have led to R#1's Acute Renal Failure on top of R#1's Chronic Kidney Failure. During an interview on 09/03/2023 at 3:22PM the primary care physician (PCP) stated, when a resident is admitted into the nursing facility, the nurses will submit medication reconciliation to doctors' office, and over the phone he will either continue or stop medications. For any additional orders the NF will call his office and notify via phone. The PCP stated he does not know why R#1 was not on glucose monitoring. The PCP stated he knew the resident forever and stated the facility may have called or not for order, but could not recollect, stated he has over 100 patients, and would expect if R#1 was on Diabetes Mellitus (DM) medications, the facility would inquire for glucose monitoring. The PCP stated R#1 has not been a long time diabetic and the lack of glucose monitoring was an oversight on his part. The PCP stated that he expected, as a collaborative effort with the clinical staff at the Nursing Facility (NF), if they see a need for a specific order, whether that's glucose monitoring or diabetic diet, to inquire about and notify him. The PCP stated he expected for the NF to advocate for the safety of all residents. The PCP stated he could not explain why R#1 was not on blood glucose monitoring, due to R#1 taking three DM medications and not on glucose checks, he stated it is a standard of care. The PCP stated if he was made aware of R#1 not having glucose checks, he would have ordered glucose checks for R#1. The PCP stated glucose checks were not only a routine of care but basic standard of care. The PCP stated his expectation of the NF would be to be proactive for patients and advocates for all residents' standard of care. The PCP stated not ordering glucose monitoring was an oversight and takes full responsibility. The PCP stated if R#1's glucose was not monitored, and R#1 was not eating, R#1 could become hypoglycemic which is severe. The PCP stated R#1 could have become too high, an incident like this (DKA) something could raise to an ungodly (critical) amount. The PCP stated he was first notified of R#1's current hospitalization on 09/02/2023. The PCP stated he does not recollect being notified about R#1's transfer to the hospital until 09/02/2023. The PCP stated 1160 blood glucose is absolutely a critical number. The PCP stated there must have been something inciting the incident either a UTI or Pneumonia, something triggered the high sugar. The PCP stated he does not recall being notified of R#1's lethargy or unconsciousness prior to R#1's hospitalization. The PCP stated the NF should have been monitoring glucose. Record review of the facility's Diabetes Management date implemented 03/12/19 and date reviewed/revised: January 2023, stated: Purpose: Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Assessment: The interdisciplinary team assesses the diabetic resident/patient upon admission, validates the orders with the attending physician and initiates plan of care that may include: Blood glucose monitoring as ordered Preventative care measures as appropriate Routine care: Blood glucose measurements shall be taken per the physician order. Results outside of ordered parameters should be communicated to the physician per orders 2.For acute events, the clinical record shall include the following information: .Blood glucose test levels . Notification of physician and any new orders. Record review of the facility's Professional Standard of Care Policy date implemented 2017 stated, Nursing Practices: a. Licensed nurses must practice within the constraints of applicable state laws and regulations governing their practice and must follow the guidelines contained in the communities' written policies and procedures. The facility Administrator and DON were notified on 09/04/23 at 3:42 PM, that an Immediate Jeopardy situation had been identified due to the above failures. On 09/06/23 at 12:08 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: Plan of Removal Immediate Jeopardy Commenced on: 9/4/2023 Situation: Resident # 1 noted with a diagnosis of Type 2 Diabetes Mellitus experienced an acute change in his condition on 8/31/23. The nurse evaluated the patient's condition, identified that he was presenting with s/s altered mental status. The nurse identified as Nurse B, checked Resident's #1 blood glucose level, the meter indicated that the reading was hi. Outcome: On 8/31/23 Nurse B then notified the physician's office of the hi blood glucose reading. Nurse B completed a change in condition SBAR and progress note describing the evaluation findings, physician's recommendations and notifications. [The physician] recommended a telehealth visit for the following day. However, the [family member] wanted the patient to be seen by physician at his office that same day. Since patient did not have an appointment, DON informed the [family member] that she could send patient to the ER to which the spouse agreed. Nurse B immediately sent Resident #1 to the emergency room for evaluation and treatment on 8/31/23. Resident #1 was admitted to the hospital and remains at the hospital. The Director of Nursing Services/Assistant Director of Nursing conducted re-education for the nurse identified as Nurse A regarding reviewing patient's plan of care to include physician's orders and care plan as well as diagnosis in order to identify diabetic patients under the nurse's care. Date commenced: 9/4/23 Date to be completion: 9/5/23 Director of Nursing / Assistant Director of Nursing conducted in-service training for the identified nurse (Nurse B) regarding the expected management of a diabetic patient, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date to be completion: 9/5/23 Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 9/4/23 Date of completion: 9/4/23 Risk Response: Residents who are diabetic and who are managed by oral medications without routine blood glucose monitoring efforts may potentially be affected by the deficient practice. Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, conducting follow up evaluation of a resident's condition upon reports of a change of condition or status by a C.N.A., proceeding with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date Commenced: 9/4/23 Date to be completion: 9/5/23 The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of orders. The nurse will update the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 9/4/23 Date to be completion: 9/5/23 Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date: 9/4/2023 Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff regarding the expected management of a diabetic patient to include: nurses should review patients under their care by review physician's orders, care plan and diagnosis so that diabetic diagnosis are known to ensure appropriate care and that physician's orders are being followed as prescribed, as well as monitoring for and responding to changes in condition for immediate consultation with the MD/NP for appropriate treatment. Evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia and following physician's orders/recommendations. Also in-serviced on the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date Commenced: 9/4/2023 Date to be completion:[TRUNCATED]