**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate care, treatment, and services to prevent complications for one 1 (Residents #56) of 2 residents reviewed for tube feedings. Resident # 56 was fed hot dog meal for lunch PO diet while he was on NPO from hospital. An Immediate Jeopardy (IJ) was identified on 06/16/22. While the IJ was lowered on 06/19/22, the facility remained out of compliance at scope of isolated with No Actual Harm with Potential for More the Minimal Harm due to the facility's need to monitor the effectiveness of their Plan of Removal corrective system. These failures placed residents at risk for perforation of the G-tube, aspiration pneumonia, replacement of the g-tube, hospitalization, or even death. Findings include: Record review of indicated Resident #56 was a 54-year- old male was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], and again 6/9/22 after pulling out his G-Tube. His diagnoses included dysphagia nontraumatic intracranial hemorrhage, (bleeding into the substance of the brain in the absence of trauma or surgery) and hypertension. Record review of Resident # 56's electronic records on 06/11/22 revealed there was no documentation for 06/09/22, there were no documentation on when and how he was admitted to the facility, there was no assessment on admission and no medication orders. Record review of facility's 24 hours report 06/09/22 revealed there was no documentation for Resident #56 on 06/09/22. Record review of NP orders dated 6/09/22 revealed GT I Glucerna 1.5cal bolus Q4hour, CBC, BMP, PT\OT. Record review of Resident #56's MAR dated June 2022 revealed no documentation of administered medication. Colum for 06/09/22 did not indicate that he was fed and provided his medication. Record review of Resident #56's nurse's note dated -6/10/2022 at 17:44 (5:00PM) written by R NB indicated Resident #56 responsible party was notified of resident receiving a regular tray of hot dog for lunch when he was noted to be NPO. Record review of Resident #56's nurse's note dated 6/10/2022 at 13:20 (1:20PM) written by RN B (Staff ID), indicated This nurse notified that Pt was noted to have a half-eaten tray at bedside given to patientt. by nursing staff. Pt is NPO, charge nurse aware. will follow up on report Record review of Resident #56's Daily Skilled Note dated 6/10/2022 at 08:20 AM, written by RN B indicated, Daily Skilled Note Resident # 56 requires Skilled Rehab for Physical Therapy (PT) Occupational Therapy (OT) and requires daily Skilled Observation for CVA Medication Management Open Wounds (e.g. vascular, surgical) Resident/Resident Representative teaching and training Tube Feeding. A drug regimen review was completed. The physician was contacted, and recommended actions were completed . Observation on 06/11/22 at 10:00AM, revealed Resident #56 was not interviewable. His Peg Tube was in place In an interview with the ADON on 06/11/22 at 1:00PM, she said the admitting nurse was supposed to assess all incoming residents, verified medication orders with attending physician and document resident's condition in electronic record. She said she was doing rounds on 06/10/22 at about lunch time when she saw Resident #56 eating lunch. She said she immediately took the tray from Resident #56 and asked the sitter not to assist him because he was NPO. She said at this time Resident #56 had already eaten half of his hot dog that was served. The ADON said, she called the NP to resident's physician and the responsible party to informed them that Resident #56 was given a lunch tray of hot dog and he eat half of it before the tray was taken away, but there was no adverse reaction. She said she assessed Resident #56 and he was alright. During a phone interview on 06/15/22 at 2:10PM, RN C said she worked the night shift on 06/09/22a she said worked a double shift on 06/09/22. She said Resident #56 admitted to the facility about 3:00pm on 06/09/22. She said she spoke to Resident #56 and welcome him back to the facility. She said she did not admit Resident #56, but she saw that Resident #56 was in no distress. She said the NP arrived shortly after to see Resident #56. She said the ADON said she would admit Resident #56, and she left it at that. She said she checked Resident #56 throughout her shift and he was alright. She said she did not check what he was on because she had no access to the computer system. She said she worked for an agency. In an interview with the facility Administrator, on 06/11/22 at 3:30PM, she said staff that worked on 6/9/22 when Resident #56 was readmitted were agency nurses. The Administrator said she did not know whether there was a system in place to ensure agency nurses were aware of the facility process for admission and readmissions. She said she would find out the agency staff that worked the night shift when Resident #56 was admitted . She said she expected assessments and documentation to be in the electronic record on admission. In an interview on 06/12/22 at 2:14PM, LVN A said she was off when Resident #56 was admitted to the facility. She said when doing her rounds between 7 :30AM and 8:00AM in the morning, she saw a meal tray for Resident #56 and knowing that he was NPO prior to being sent out, she took the tray from Resident #56, and ask one of the aide on duty not to feed Resident #56 because he was on G-Tube feeding. She said she immediately left to review his orders in electronic record but there were no orders entered. She said she looked around and found Resident #56's discharge records at the nurse's station. She said she reviewed the orders and called the NP who told her she reviewed Resident #56's orders on 06/09/22 with someone at the facility. She said she proceeded with resident's orders, fed him, and continued with her routine assignment. She said she did not go back to the kitchen to find out how Resident #56 got a tray. She said she was not aware that a lunch tray was passed out until after the incident. In an interview on 06/12/22 at 1:30PM, [NAME] CC said he usually followed what was on resident's meal ticket but if a staff member asked for a tray for resident, he would give out a tray. He said, there is usually there would be a meal ticket with Resident's name. He said he does not remember who asked for a tray for resident #56. In an interview on 06/13/22 at 12:00 PM, the dietary Manager said she was new to the facility. She said the facility does not have a system of tracking trays for an extended period of time. She said the system generated meal tickets daily and if the resident was new, someone from the nursing staff had to request or provide a meal ticket before getting a tray. She said she printed out her meal ticket daily from the facility's system called (SNOW). She said she was told by the kitchen staff that someone had asked for a tray for Resident #56. She said she did not find any meal ticket for Resident # 56. She said she checked the system and Resident #56 was NPO. In an interview with MA K on 06/14/22 at 3:00PM, she said she saw the tray and assisted Resident #56 with his hotdog. She said she did not feed Resident #56. She said she assisted resident #56 by putting his hot dog together. She said Resident #56 ate the hot dog without assistant. She said halfway through eating the ADON came in and said Resident #56 was NPO and was not supposed to have a tray. She said at that time the tray was taken away from Resident #56. In an interview on 06/15/22 at 02:15 PM with the interim DON stated there was an order for a chest X-ray by a nurse, the nurse was unknown. The physician was made aware that nurse had ordered an X-ray. She said it was her understanding that the NP saw resident on Thursday 6/09/22 and gave orders to continue with discharged orders. She said the NP usually visited all residents on a weekly basis. She said the documentation by the NP were not readily available because their documentation usually goes through their system and it takes about a week. She said the nursing staff did not do the admission assessment. She said there was no admissions note that the resident had returned. She said good nursing practice was, on admission, there should be a full assessment of resident and document the assessment. She said a new chest X-ray was ordered today 06/15/22 by the NP. During an interview with the NP on 06/17/22 at 12:00PM, she said she saw Resident #56 on 06/09/22 about 11:30 to 12:30PM, and wrote an order to continue with discharge orders. She said she does not remember the nurse that was present. She said her notes had to go through their cooperate system before being available to the facility. She said she remember being notified about the hotdog and that Resident #56 was alright, she said she does not remember the time but she was notified. The NP had not response when this surveyor told her that the residents documentation revealed Resident #56 got to the facility about 3:00pm. In an interview on 06/11/22 - at 1:30pm, [NAME] AA said all she does was to follow diet order. She Said all residents that eat from the kitchen had a meal ticket but sometimes staff can request for a tray. She said if a staff requested for a tray, they would give out tray upon request. In an interview on 06/11/22 at 1:50PM, LVN T said all new and re-admit residents are assessed and made comfortable, then review discharge records from hospital and reconciled all medication with the attending physician and if they were new to the facility call the on-call physician group. LVN T said the admitting nurse had to consult the on-call physician third eye to reconcile medication and document information in electronic record and document in 24 hours report. In an interview with the facility Administrator, on 06/11/22 at 3:30PM, she said staff working on 6/9/22 when resident #56 was readmitted were agency nurses. The Administrator said she did not know whether there was a system in place to ensure agency nurses were aware of the facility process for admission and readmissions. She said she would the staff that worked the night shift when Resident #56 was admitted . She said she expect assessment and documentation to be in the electronic records. In an interview on 06/12/22 at 1:30PM, [NAME] CC said he usually follows what is on resident's meal ticket but if a staff member asked for a tray for resident, he would give out a tray. He said, there is usually a communication sheet which is written on the meal ticket. He said he does not remember who asked for a tray for resident #56. In an interview with [NAME] BB on 06/12/22 at 2:40PM, he said he only pass out tray on the cart. He said he had no idea who is was on NPO and who is was on diet. In an interview on 06/12/22 at 2:14PM, LVN A said she was off when Resident #56 was admitted to the facility, she said when doing her rounds between 7 :30 and 8:00am in the morning, when she saw a meal tray for Resident #56 and knowing the resident being on NPO prior to being sent out, she took the tray and ask the aide on duty not to feed Resident #56 because he was on G-Tube feeding. She said she immediately left to review his orders Resident # 56 electronic records but there were no orders. She said she looked around and find resident #56's discharge records at the nurse's station. She said she reviewed the orders and called the NP for Resident's physician who told her that she reviewed Resident #56's orders on 06/09/22 with someone at the facility. she said she proceeded with Resident's orders, fed him, and continued with her routine assignment. She said she did not go back to the kitchen to find out how Resident #56 got a tray. She said she was not aware that a lunch tray was passed out until after the incident. In an interview on 06/13/22 at 12:00 Pm, the dietary Manager said she was new to the facility. she said the facility does not have a system of tracking trays for extended period. She said the system used generate meal ticket daily and if the resident is new, someone from the nursing staff had to request or provide a meal ticket before getting a tray. She said she prints out her meal ticket daily from the facility's system called (SNOW). She said she was told by the kitchen staff that, someone had asked for a tray for Resident #56. She said she did not find any meal ticket for Resident #56. She said she checked the system and Resident #56 was NPO. In an interview with RRD on 06/13/22 at 1:00PM, she said the facility system generated meal ticket daily. She said she has had an inservices with all staff and will continue to have inservices till all staff are covered. She said she will come up with a system where all meal tickets are tracked and posted daily on the nurse's station and in the dining room. During an interview with MA K, on 06/14/22, she said she saw the tray and assisted resident #56 with his hot. She said she did not feed Resident #56. she said she assisted resident #56 by putting his hot dog together. She said Resident #56 eat hot dog without assistant. She said halfway through the ADON came in and said that Resident #56 was NPO and not supposed to have a tray. During a phone interview on 06/15/22 at 2:10PM, RN C that worked the night shift on 06/09/22 at 2:10PM, she said worked double shift on 06/09/22. She said Resident #56 came in at about 3:00pm on 06/09/22. She said she spoke to Resident #56 and welcome him back to the facility. she said she did not admit Resident #56 but see that Resident #56 was in no distress. She said the NP arrived shortly after to see Resident #56. She said the ADON said she would admit Resident #56, and she left it at that. RN C said she checked Resident #56 throughout her shift and he was alright. She said she did not check what he was on because she had no access to the computer system. She said she worked for an agency. In an interview with facility Administrator on 06/15/22 at 02:09 PM, she stated Resident #56's physician was out of the country on vacation. She said she would have to check to see if Resident #56 has had seen a doctor since he has been here at the facility. Not sure if resident's physician was notified of his condition the day of the incident. 06 /15/22 at 02:15 PM, interview with interim DON stated that there was an order for a chest X-ray by a nurse, nurse unknown. Unknown what Doctor, but doctor was made aware that one of the nurses ordered X-ray. She said she would have to get the chart to verify chest X-ray. She said it was her understanding that NP saw resident on Thursday the 9th. She said NP usually visit all residents on a weekly basis. She said the (Gerimed) documentation by the NP are not always readily available because their documentation usually goes through their system and it takes about a week. She said the nursing staff did not do the admission assessment. She said there was no admissions note that the resident had returned. She said good nursing practice is at admission, do a full assessment of resident and document the assessment. She said a new chest X-ray ordered today by NP on 06/15/22. During an interview with NP on 06/17/22 at 12:00pm, she said she saw Resident #56 on 06/09/22 and wrote an order to continue with medication. She said she does not remember the nurse that was present. She said her notes had to go through their cooperate system before being available to the facility. she said she does not remember being notified about the hotdog, but she was notified. She said she saw Resident #56 at about 11:30 to 12:30pm. She said nothing when told that documentation revealed that resident #56 got to the facility at about 3:00pm. During an interview with Dietary manager on 06/18/22 at 2:30 M, she said the facility had put a system in place where diet tickets must be used to distribute meal trays. She said there would also be a system where meal orders are kept and reference when needed for a month, assessable to all dietary staff and nurses. She said she had in-services with all dietary staff on giving out meal tray without a communication sheet. In an interview with the facility Administrator on 06/18/22 at 2:00pm 00PM, she said all agency staff and facility staff are being in-service on admission of new and readmit residents, documentation, and a step-by-step instruction on how to input information in the electronic system. Record review of facility's policy, on admission dated 08/11/13 admission Policy dated 08/11/13 read in part- the purpose of the admission policy is to provide continuity of care and services between discharging provider and the admitting facility admission: . o Obtained and review transfer health record o Complete clinical evaluations o Verify transfer orders o Verify admission physician and resume previous orders with attending physician against those from hospital Record review of the facility's NF Policy titled, Dining Communication dated 06/28/13 revised 5/12/16 read in part Each dining location will have a diet, mealtime communication notebook for reference during meal services. Staff will be aware of all residents requiring swallow precaution as noted in the dining room communication notebook An Immediate Jeopardy (IJ) was identified on 06/16/22 at 1:30PM, due to the above failures. The Administrator was notified on 06/16/22 at 1:30PM, an of the IJ situation was identified due to the above failures and the IJ template was provided on 06/16/22 at 1:30 PM. The Plan of Removal was accepted on 06/17/22 at 4:00PM. and included: PLAN OF REMOVAL The Lakes at Texas City Date:06/17/22 Removal of Immediacy This Plan of Removal represents the center's allegation of compliance as of 6/16/2022. The Texas Health and Human Services Commission entered The Lakes at Texas City[facility name] on a complaint investigation which started on 6/11/2022. The plan of removal serves as The Lakes at Texas City response to the Immediate Jeopardy Notification the center received at 1:30 pm on June 16, 2022 from the Texas Health and Human Services Commission related to 1. Failure to ensure a resident who is fed by enteral means receives appropriate treatment and services to prevent complications Resident # 56 Resident # 56 is a 54 Y/O male who has resided at the center since 5/23/2022 with the following diagnosis: CVA, Dysphagia, Hemiplegia, Dysarthria, Hypertension This facility has 1 additional tube fed resident that has been receiving a no restriction diet, pureed texture since 3/25/2022. The MD discharge instructions from the hospital on 6/6/2022 state to resume home diet/feeds. What happened briefly is as follows: On 6/10/2022, Resident #56 was served a regular meal of a hot dog. Resident #56 ate half of the meal prior to the tray being removed. Resident #56 had no adverse outcome from this isolated incident. As part of facility investigation, a chest x-ray was obtained to verify no adverse outcome from isolated incident was obtained on 6/15/2022. Xray findings revealed no focal infiltrates with no pleural effusion noted. Speech therapy completed screen prior to incident on 6/10/2022 and evaluated after the incident. Staff immediately notified Speech Therapy that resident had consumed a regular diet tray. The Speech Therapy also notified charge nurse and ADON. Speech Therapy evaluated the situation and to follow with nursing and dietary staff for appropriate feeding consistency for the weekend. ST provided recommendations for continuation on NPO. On 6/10/2022 Resident #56 family member was notified (Resident #56) receiving a regular tray for lunch. Complete incident investigation initiated by the facility to include staff interviews and staff in servicing. The physician was not notified at the time of the incident by the ADON nurse. The ADON nurse failed to notify physician and this failure resulted in her termination. The NP was notified on 6/10/2022 regarding resident #56 receiving a regular tray. Resident #56 was admitted on [DATE] and assessed by NP and orders were received to restart peg tube feeding with Glucerna 1.5 Cal bolus every 4 hours, add 100 mL water flush before and after each bolus feeding, Monitor GT site and residuals. On 6/10/2022, LVN A entered order into electronic system. On 6/16/2022, the new dietary manager was educated on tracking diets and changes in the SNOW tray card system versus electric system. Immediate Action taken 1. On 6/16/2022 Regional Nurse Consultant identified that no other residents have the potential to be affected by this alleged deficient practice. All current and new facility resident's orders were audited for accuracy in [electric system].PCC and SNOW tray card system. Audit revealed facility currently only has 1 resident with NPO order. 2. On 6/16/2022 The Facility Dietary Manager completed audit of all residents to ensure that all diet orders matched the physician's order. 3. On 6/16/2022 Education was provided to facility dietary and nursing staff to include licensed nurses, medication aides, and nurse aides by the Regional Dietary Consultant which began on 6/13/2022 during this investigation on: A. Serving Diets and Diet Change Process with Post Test B. Dietary Orders 4. On 6/16/2022 Education was provided for facility nurses by the DON/designee on admission Policy Process to include admission and readmission assessment and transcribing orders. Any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employees. Education was completed on 6/16/2022 and going forward education will be provided for agency staff who has not received training prior to working. 5. On 6/16/2022 Education was started for C.N.A.'s by the DON/Designee on: A. Resident Care tool use to Identify residents who are NPO Any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employees. Education was completed on 6/16/2022 and going forward education will be provided for agency staff who has not received training prior to working. 6. On 6/16/2022, The facility will ensure all agency and PRN staff will be orientated on obtaining, verifying, and following readmission orders to include assessment and diet orders prior to working. Any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employees. Education was completed on 6/16/2022 and going forward education will be provided for agency staff who has not received training prior to working. This education was completed on 6/16/2022, any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employee's Monitoring Administrator/DON/Designee will use a QAPI meal monitoring Audit tool daily to include new/readmissions x 2 weeks, then weekly x 2 months to monitor that: A. New/Readmit Residents are receiving appropriate diets per physician orders B. All current and new facility resident's orders were audited for accuracy in [electric system].PCC and SNOW tray card system. Audit revealed facility currently only has 1 resident with NPO order. C. On 6/16/2022 The Facility Dietary Manager completed audit of all residents to ensure that all diet orders matched the physician's order. QAPI Meeting The Admin and/or designee will report any findings to the Quality Assessment and Assurance committee monthly in QAPI meeting for a minimum of 3 months or until compliance is ensured. The Quality Assessment and Assurance Committee validates the actions taken are effectively resolving the cited issues and verifies the dates of completion. Surveyor conducted Monitoring monitored as follows: the facility implemented their plan of removal sufficiently to remove the IJ by: Interview on 06/18/22 at 12:10 PM, LVN G said she was an agency nurse. She said she had an in-service this morning -06/18/22 on resident's admission and she was given a step by step on what to do and how to enter information in electric system. Interview on 06/18/22 2022 at 1:10PM, MA 1:10PM, MA I said she had an in service on 06/17/22 on feeding residents and not to ask any kitchen staff for food for resident. She said all meal request must go through the charge nurse and not to feed Residents until she clarify with the charge nurse. Interview on 06/18/22 at 1:20Pm20PM, LVN H said she was an agency Nurse. She said she had an in-service this morning on admissions, following up on physician orders, and ensuring that all orders are put in electric system She said she was given a step by step process on how to input information in electric system. In an interview with the Facility Administrator on 06/18/22 at 3: 00Pm00PM, she said all agency staff and facility staff including dietary staff had been in-service on how to access and use electric system in verifying resident's information and orders, especially new admission and readmission. All nurses are in-serviced on documentation. An interview on 06/19/22 at 03:13 PM, with Corporate nurse, RN X revealed, Hospice usually services when a Resident #1 is was hospitalized . Resident #1was dehydration due to fluid refusal and decline in condition. Plan of Removal went into electric system and the snow SNOW tray card system to ensure orders and tray card system matched and everyone had a diet even if it said NPO. Conducted by Dietitian. Rescreen all residents with a Dysphagia diagnosis, noted screening notes. Nursing in-service root cause of failure: Admission/readmission process 1. Orders 2. Clarification of orders (discharge identify and put them in the system and indention differences from the dr.) education: on admission/readmission process. Created a cheat sheet to ensure staff have completed the required steps when a new/readmit of residents. Not part of the clinical record. A tool as needed. Shift routine requirements. Nursing to dietary communication sheet: required form and follow the admission process and complete the form. Staff required to follow admission policy & required to complete diet communication form that goes to the kitchen and one that stays in resident's chart. She said checking chart to ticket was a part of resident's care tool located at each station diet list in the care tool book. Staff can look up a Resident # in the tool book and see additional needs and preferences. CNAs have a listing of everyone's diet within the whole facility. Don't give any Resident #1any snack/food/drink until you know what they diet was. Diet ordered are required to presented to the kitchen before any tray will be passed. QAPI on a daily basis. Kitchen Manger was monitoring the diet cards every day. An interview on 06/19/22 at 04:13 PM the Corporate RN X revealed readmission process paperwork on Resident #2 will be provided . An interview on 06/19/22 at 04:40 PM with Corporate RN, Administrator, DON, and regional RD were informed the IJ was lowered, and exit planned for tomorrow. It was lowered, however, the facility remained out of compliance at scope of isolated and severity of no actual harm with a potential for more than minimal harm as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.