**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 73 was admitted to the facility on [DATE] with diagnoses that included osteoporosis with pathological fracture, sarcoidosis, repeated falls, patellofemoral disorders of left knee, weakness, myelopathy, anxiety disorder, and depression. On 10/2/23 at 10:46 AM, an interview was conducted with resident 73. Resident 73 was observed to be sitting in a wheelchair in her room at the time of the interview. Resident 73 stated that shortly after she was admitted , a Certified Nursing Assistant (CNA) and a trainee wanted to do a brief change before the end of the shift. Resident 73 stated she tried to tell the CNA that she did not need a brief change, but the CNA insisted. Resident 73 stated the CNA was unable to do a brief change while she was in her recliner so the CNA attempted to change her brief while standing and her right knee began to hurt. Resident 73 stated she heard a pop and she experienced significant pain. Resident 73 stated the nurse assessed her and she was sent to the hospital for care. Resident 73's records were reviewed between 10/2/23 and 10/10/23. Discharge documentation from the [hospital], dated 9/6/23, revealed: a. Physician notes stating, Reduced R (right) knee subluxation-Continue splint when doing PT (physical therapy) or walking. Per Ortho (Orthopedic) 8/23-keep right knee immobilized. Goal is to create some scar tissue to prevent future dislocations. b. Occupational therapy notes dated 9/6/23 included RLE (right lower extremity): Knee immobilizer, WBAT (weight bearing as tolerated). c. Physical therapy notes dated 9/6/23 included RLE: Knee immobilizer, WBAT. A review of resident 73's admission Minimum Data Set (MDS) dated [DATE] revealed that resident 73 required two + person extensive assistance with transferring. When moving from a seated to a standing position, the MDS revealed that resident 73 was not steady and was only able to stabilize with staff assistance. Walking activities did not occur, and resident 73 used a wheelchair for mobility. Resident 73's Brief Interview for Mental Status (BIMS) revealed a score of 15, indicating the resident was cognitively intact. Resident 73's care plan dated 9/7/23 revealed that assistance required on admission was 2 person supportive assistance. No documentation related to knee immobilization or that the resident had a knee immobilizer was found. Resident 73's progress notes revealed: a. On 9/7/23 at 12:53 PM, an admission summary note documented, new admit expected [AGE] year,with dx (diagnosis): narcosarcoidosis (sic), vertebral fx(fractures), pmh(past medical history): osteoporosis, anxiety, adhd [attention deficit hyperactivity disorder], anemia. axox(alert and oriented times) 4, dev (developmental) delay. reg (regular) diet, skin reported to be but not seen yet, redness to buttock, teds for edema, r (right) leg immobilizer, old surgical site to buttock. incant (incontinent) b/b(bowel and bladder), last bm (bowel movement) 9/7, takes oxy (Oxycodone) 5mgm [milligram], ibuprofen and [NAME] (Tylenol) for pain. reg (regular) diet, reg text, thin liquids, [NAME] (sic.) transfer, 2 ext (extensive) asst (assistance), cbc (complete blood count) cmp (complete metabolic panel) for tomorrow. exp (expect) arrival 1 ish. b. On 9/7/23 at 2:39 PM, an additional admission summary note documented that resident 73 was admitted and settled into her room. The note stated that resident 73 required a Hoyer transfer. c. On 9/8/23 at 10:25 AM, a skilled progress note documented that resident 73 bears no weight to right leg or to left leg. Pt has unsteady gait requiring supervision. Patient has impaired balance. Weakness present. The note also documented that a Hoyer lift was required for all transfers, and bed mobility and transfers required two+ person physical assistance. patient does not verbalize pain, rates pain 0 on a scale of 0-10. d. On 9/8/23 at 1:15 PM, a physician progress note documented that resident 73 had an extension brace on the right knee. The note also included, She recently had a fall at home and dislocated R knee. Her goals are to get knee brace off and goal to gain a little more mobility to get home. e. On 9/9/23 at 6:38 PM, progress notes documented that resident 73 was administered 5 mg of Oxycodone for pain. The note also stated, pt reporting high levels of pain following an incident with staff. See Progress note. f. On 9/9/23 at 6:52 PM, a progress note revealed that the medication administration was ineffective. The follow-up pain scale was 7. g. On 9/9/23 at 10:41 PM, a nurses note documented, RN [registered nurse] called into pt's [patient's] room at shift change. Pt was sobbing and telling RN that she was hurt by CNA's who had just changed her brief. Pt was asked to tell RN what happened and reported that CNA's came in and told pt that they needed to change her brief. Pt states that she responded by telling CNA that she was dry and did not need her brief changed. CNA insisted that it be changed prior to shift change and pt was told that they would be moving her into the bed to change her brief. Pt told CNA that she was not ready to be put into the bed. CNA proceeded to change resident in chair but was having difficulty. It was then that pt reports that she was made to stand. Pt states that she protested and told CNA that she was non weight bearing and that she was not supposed to be standing and that it was hurting her. Pt then told CNA that her ankles were going numb and her R knee was in significant pain. Pt reports having the CNA respond with 'you'll be fine.' Pt's R knee then popped and became even more painful than her base line. PT's family also called and asked that something be done. Case was reported to [Administrator]. Pt was given oxy [Oxycodone] 5mg to help ease her discomfort. Pt reported 0 improvement in pain after 30 minutes. On-call [provider] was notified of the situation and agreed that we should listen to pt's request and send her out to hospital for evaluation. 911 was called, pt was ambulanced to [Hospital omitted]. Transportation team notified of potential need to bring her back tonight. Hospital was contacted, given report, and asked that pt not be sent back via ambulance. ER [emergency room] took number to facility to call us and let us know when she will need to be transported back. h. On 9/10/23 at 4:02 AM, a progress note documented, Pt returned back to the facility from [Hospital omitted] ED [emergency department] at 02:45. Pt's Diagnosis for this visit is subluxation of right patella, initial encounter. Instructions are: Patient must be non-weight bearing in her right leg and in her long-leg immobilizer at all times while moving. Imaging tests of XR knee 1 to 2 views RT were completed. i. A provider note dated 9/28/23 documented, on 9/9/23 Pt went to the [Hospital omitted] ER r/t (related to) knee pain. She states was being transferred by staff and felt knee pop and subsequently was in a lot of pain. Pt was sent to ED for further evaluation upon request. ED diagnosed a subluxation of R patella, that was reduced upon arrival. New orders to non-weight bear on R leg and be in long-leg immobilizer at all times while moving. A physical therapy evaluation dated 9/8/23 revealed: a. Lower extremity- RLE strength =2-/5 (Part moves partial range on a gravity eliminated plane); LLE strength= 2-/5 (Part moves partial range on a gravity eliminated plane) b. Pain assessment included, Pain at rest-intensity = 3/10; Frequency/Duration=Daily; Location: R knee; Pain description/Type: Aching and sharp. Pain with movement-intensity = 7/10; Frequency/Duration=Daily; Location: R knee; Pain description/Type: Aching and sharp. c. Functional Assessment included, Bed mobility = Max; Transfers = Total dependence w/ attempts to initiate; Gait=Level surfaces = DNT (do not try) d. Assessment Summary Impressions included, .Pt had a recent GLF (ground level fall) resulting in R knee injury. Pt is in a knee immobilizer and reports increased pain .Pt presents as a high fall risk with decreased functional strength and activity tolerance, balance deficits, and increased need for assistance with gait, transfers and bed mobility tasks. An after visit summary from the hospital dated 9/9/23 included instructions that Patient must be non-weight bearing in her right leg and in her long-leg immobilizer at all times while moving. The reason for the visit stated Knee pain-acute traumatic injury, and the diagnosis was subluxation of right patella, initial encounter. The triage notes stated Pt reports she dislocated her R knee 1 month ago. She was non weight bearing per her recovery plan until today when at [facility] she was prompted to get up and have her brief changed by CNA's and she felt her R knee slide and pop. Pt did not fall in this incident. Pt currently in R knee brace. Pt endorses numbness and tingling in R knee and both ankles. Pulses present. On 10/10/23 at 10:03 AM, an interview was conducted with CNA 1. CNA 1 stated resident 73 was transferred multiple times every day. CNA 1 stated resident 73 was usually in her recliner until after dinner each day. CNA 1 stated CNA's go into resident 73's room to reposition her and change her brief. CNA 1 stated resident 73 was incontinent but she knew when she needed to be changed and was able to call for assistance when she needed a brief change. On 10/10/23 at 10:20 AM, an interview was conducted with the Unit Manager (UM). The UM stated when a resident was injured, the staff should get the nurse immediately. The UM stated the administrator was notified immediately after the nurse assessed resident 73 on the date of the incident. On 10/10/23 at 3:20 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated on 9/9/23 during shift change, she was taking report from the daytime nurse. RN 2 stated a CNA came and told her that resident 73 was crying and was in pain. RN 2 stated she was told resident 73's knee popped. RN 2 stated she went to resident 73's room and the resident told her the CNAs were trying to change her brief while standing. RN 2 stated resident 73 told her she had told the CNA that she was not ready to go to bed and that she was dry and did not need a brief change. RN 2 stated she was told by resident 73 the the CNAs told her they had to change her. RN 2 stated she was told by resident 73 that the CNAs tried to change her brief while she was in the recliner but were unable to do it. RN 2 stated she was told by resident 73 that the CNAs had her stand up so they could change her brief. RN 2 stated she was told by resident 73 that her knee popped and she was in pain. RN 2 stated she obtained some pain medication and asked resident 73 if she could wait 30 minutes to see if it was effective. RN 2 stated after 30 minutes the pain medicine had not been effective and resident 73 requested to go to the emergency room. RN 2 stated she contacted the provider on call who agreed to send resident 73 to the emergency room. RN 2 stated about the same time as she was preparing resident 73 to go to the emergency room, she received a phone call from resident 73's sister who requested she go to the emergency room. RN 2 stated resident 73's functional status was that she was non-weight bearing and required a Hoyer lift for transfers. RN 2 stated resident 73 had an immobilizer for her knee, but her recollection was that it was down near her ankle at the time she assessed her on 9/9/23. RN 2 stated resident 73 was alert and oriented x4, indicating she was oriented to person, place, time and situation. RN 2 stated that resident 73 knew if she needed a brief change and would call for staff if she needed a brief change. RN 2 stated CNAs received information about the residents through huddles and by the CNA reports during shift change. RN 2 stated she tried to find the CNA that was working with resident 73 and was unable to find her. On 10/10/23 at 3:40 PM, an interview was conducted with CNA 3. CNA 3 stated she was not the CNA that transferred resident 73. CNA 3 stated prior to going into resident 73's room, a nurse and a trainee lifted resident 73 from her bed into her recliner without using a Hoyer lift so she had nothing to work with. CNA 3 stated it was not my fault. CNA 3 stated resident 73's brief change was completed while she was in her recliner. CNA 3 stated she completed the brief change by reclining the chair all the way back and rolling resident 73 from side to side. CNA 3 stated on the chat other CNAs had talked about changing residents while in a recliner. CNA 3 stated she had asked resident 73 if she was ok and resident 73 stated she was fine. CNA 3 stated she told the night shift CNA what happened. CNA 3 stated her recollection was that resident 73 had a brace above her knee at the time. CNA 3 stated resident 73 did not necessarily have a problem with her memory but she was special. CNA 3 stated that resident 73 did not request a brief change. CNA 3 stated resident 73 was able to say if she needed her brief changed and would ask. CNA 3 stated if a resident refused to have a brief change she would ask the resident if she could check the brief anyway to be sure. CNA 3 stated staff could not push or force residents. CNA 3 stated she received information about residents care needs during the shift change report. CNA 3 stated she last worked at the facility on 6/19/23 before having knee surgery. CNA 3 stated she was a float at the facility and went between two hallways. CNA 3 stated she was working with a trainee the last time she worked. [Note: CNA 3's time cards were pulled and CNA 3 was working at the facility at the time of resident 73's injury.] It should be noted that the information provided by CNA 3 was inconsistent with the information provided by RN 2. On 10/10/23 at 4:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the administrator was at the facility when the incident with resident 73 occurred. The DON stated a CNA and a CNA student were trying to change resident 73's brief and in the process the resident had some pain. The DON stated the CNAs were trying to change the resident in the chair. The DON stated the CNAs wanted to be sure the resident was changed. The DON stated she thought the CNAs had the brace on resident 73. The DON stated resident 73 complained of pain and the CNAs reported to the nurse. The DON stated that resident 73 said the CNAs wanted to be sure the brief change was done and she felt rushed. The DON stated resident 73 acknowledged the staff had no intent to harm her. The DON stated the CNAs made sure resident 73 was taken care of. The DON stated she was not aware that resident 73 had stated she did not need a brief change. The DON stated if a resident stated they did not need a brief change she would expect the CNAs to respect the residents preferences. The DON stated some residents did not know if they were wet and the CNAs ask if they can check. The DON stated she had spoken with resident 73 two times and she was coherent, alert and oriented. The DON stated resident 73 required a Hoyer lift for transfers from bed to chair. The DON stated that staff communicate the needs of resident care during shift reports. The DON stated if the CNAs have questions about the residents they could always ask the nurses. The DON stated resident 73 had a knee immobilizer when she arrived, but it was for her comfort. The DON stated resident 73 was weight bearing as tolerated. The DON stated resident 73 did not have an order for an immobilizer when she was admitted . The DON stated after going to the ER, the discharge orders stated to keep the immobilizer on at all times. On 9/9/23 at 8:10 PM, an entity 358 form was submitted to the State Survey Agency (SSA) stating that resident 73 had reported that her knee slipped/popped when being transferred. On 9/14/23 at 11:07 AM, an entity 359 form was submitted to the SSA with the facility investigation. The outcome(s) documented that resident 73 had increased pain in her knee, no change in baseline ability, and no change in range of motion. The investigation documented that the subluxation of right patella was included in resident 73's initial paperwork from the hospital when she admitted on [DATE]. emergency room documents after the incident included instructions for resident 73 to be non-weight bearing on right leg and wear her immobilizer at all times when moving. Interviews conducted in the investigation interviews included: a. Resident 73 on 9/9/23 at 7:00 PM. The interview revealed, Patient reports that her knee was hurting/throbbing. She said that she came to Stonehenge because of a fall, in which she hit her head. Her back was cracked and she had dislocated her knee when getting in a car a few days after the fall. She has a history of surgery to her other knee (left) and she is worried about her right knee, which she called her good knee. Patient felt that on 9/9 the CNA was trying to hurry to get her changed. She had told the CNA and accompanying student that she didn't want to get in bed, so they tried to change her standing up. She expressed that she felt she wasn't being listened to by the CNA when she said it was hurting. [Resident's name removed] stated that she felt they were trying to hurry to get done. She stated that she did not feel that there was malicious intent, just trying to get the task completed. b. Student CNA (CNAT) who stated nothing stuck out to her during her time with [CNA 3]. Nothing of concern occurred while changing the patient. She has been a CNA for several years, who needs to get recertified. States that she would have notified her instructor immediately of any abnormal occurrences or incidents during training. States that they changed patient in her recliner because the patient did not want to be transferred to the bed. During the change, the patient said that her knee was hurting, but she did not appear to be in distress. Knee brace was on patient. Felt that the [CNA 3] was sweet & kind to all patients during her 12 hours with her. [It should be noted that the notes provided to the State Agency (SA) taken by the ADM from the interview of CNAT had written at the top Nothing stuck out to her. Wasn't absolutely sure that she remembered the right patient but said [CNA 3] was kind and respectful of all.] c. CNA 3 on 9/9/23 at 8:20 PM. The interview revealed, Patient got changed in chair-tried to change her while standing, but patient said it was hurting so put her back in chair. Did not hear anything pop. Patient wanted to be back in chair. Didn't have a sling under her. Was with a student who was a CNA before, but is renewing license. Checked that knee was in right position prior to getting up. d. Other residents were interviewed by the social worker. All the residents stated they felt safe in the facility and have never witnessed or heard anyone being treated inappropriately. e. Registered Nurse (not named in the investigation document) during the shift stated she had received no complaints and that CNA 3 appeared to be a hard worker. f. The unit manager stated CNA 3 was a very hard worker who was one of the best CNAs on the hall. g. The staffing coordinator stated staff enjoyed working with CNA 3 and that there had been no complaints. h. The Assistant Director of Nursing (ADON) stated that CNA 3 was task oriented and seemed to understand the needs of the residents. The ADON also stated that CNA 3 did her best to complete tasks efficiently and effectively. The summary information of the investigation stated, On admission to facility, patient had a diagnosis of subluxation of right knee, no orders for non-weight bearing. Patient also has a diagnosis of neurosarcoidosis and developmental delay. Documentation from ER visit indicates that patient had subluxation of right patella, with orders for non-weight bearing and wearing immobilizer. Patient has had no signs or symptoms. The allegation was not verified by the facility investigation. No information was provided as to why the allegation was not verified. Additional information provided by the facility after the recertification included: a. A statement provided by RN 4 documented, On 9/9/23 at shift change the patient (resident 73) was crying and in a lot of discomfort in her room. She was sitting in her recliner and stated that her R knee was hurting a lot. She stated that she thought it was dislocated during the transfer because she felt it pop. She stated that she has a history of it dislocating. It was noted that the patient did have a brace/immobilizer in place to her RLE. The oncoming nurse came in and assessed the patient who was eventually sent to the hospital. b. An orthopedic physician note from 9/15/23 that was not found in resident 73's medical record during the survey. They physician noted included: 1. Chief complaint: Right knee pain. 2. History and Physical: Resident 73 presented for evaluation and treatment of right knee pain. Symptoms began 1 month ago when she was trying to get into a car. She experienced a patellar dislocation that had to be reduced in the ER. This was the first time dislocation on the right knee, but she has a history of L knee patellar instability for which she had surgery as a child. She has been in a [NAME] (knee immobilizer) for the last month. 3. Past pertinent history: Resident was seen previously for the same pathology by ED, treatment rendered included immobilization, NWB (non weight bearing), referral. Based on observation, interview and record review it was determined, for 2 out of 31 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a fall from occurring which resulted in a fracture and care planned interventions were not implemented, adequate, or timely. Additionally, the facility did not provide adequate supervision or assistance during incontinence care which resulted in a dislocation of the resident's knee. The identified deficiencies were determined to have occurred at a harm level. Resident identifiers: 66 and 73. Findings included: HARM 1. Resident 66 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral vascular accident, insomnia, type 2 diabetes mellitus, malignant neoplasm of rectosigmoid junction, major depressive disorder, anxiety disorder, hypothyroidism, obstructive sleep apnea, hyperlipidemia, hypertension, dependence on supplemental oxygen, obesity, history of falling, dysthymic disorder, vascular dementia, mood affective disorder, and osteoarthritis. On 10/03/23 at 10:33 AM, an interview was conducted with resident 66. Resident 66 stated that she broke her ankle, but did not recall how she broke it. An observation was made of resident 66's foot brace/boot placed in a wheelchair at the bedside. Resident 66 was observed on a air mattress, the bed was at hip height, and no fall mats were located at the bedside. It should be noted that resident 66's room was the last room on the hallway and furthest away from the nurse's station. Resident 66's physician orders revealed the following: a. Non-weight bearing on left lower extremity related to fibula fracture. May wear boot for comfort/support. After September 30, 2023, patient may advance to weight bearing in boot. The order was initiated on 9/20/23. b. Keep bed in lowest position every shift for fall risk. The order was initiated on 3/4/2023. On 8/27/23, the Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) of 8/15, which would indicate a moderate cognitive impairment. The assessment documented resident 66's functional status as a one person extensive assist for bed mobility, dressing, and toilet use; limited one person assist for eating; and one person physical assist for ambulation in room and corridor. Resident 66's progress notes revealed: a. On 3/4/23 at 12:41 PM, the note documented, Per On-call [name omitted], X-Ray 2V [views] of R [right] knee to r/o [rule out] fracture r/t [related to] unwitnessed fall. b. On 3/4/23 at 7:31 PM, the note documented, X-ray result received. No acute injury of R knee noted. Per on-call NP [Nurse Practitioner] request, on-call NP notified. Per NP, no new orders. Family notified. c. On 3/6/23 at 7:20 PM, the note documented, 3/4 - 3/7 unwitnessed fall. Xray of R knee completed. No new orders. Took meds [medication]. Tolerated well. No adverse effects noted. No new injuries noted from fall. Will continue to monitor. d. On 9/10/23 at 5:02 PM, the note documented, Upon walking into resident room CNA [certified nurse assistant] noted patient with buttocks on floor back against back of bed. This nurse was in hallway outside room notified of fall, went into room to assist patient. Patient stated she needed to go to the bathroom when she got up and feet slipped from underneath her. Patient checked for injuries, assisted x3 [times 3] staff up from floor to bed, 2 staff assisting upper body while one staff holding lower extremities. Patient obtained a abrasion on base of big toe to left foot which she stated she stubbed her foot on table. Initially no other injuries noted. She did complain of pain to her toe initially. Gave her PRN [as needed]tramadol and tylenol to assist with pain. Notified all appropriate persons- [family member name omitted], on call MD [Medical Doctor] and administrator in building. e. On 9/10/23 at 5:12 PM, the note documented, Within about 30 minutes after fall patient started complaining about increased pain to left ankle and leg. Even attempts to pull patient up in bed or turning had become difficult. Called spoke with on call physician asked for orders for Xray of entire left leg due to patients inability to tell me exactly where the pain is. Received orders for 2 view xrays of entire L [left] leg, knee, foot and hip. Also increase in Tramadol to 100 Q8H [every 8 hours] per [name of Nurse Practitioner omitted]. f. On 9/10/23 at 5:29 PM, the note documented, Radiologist came to do xray of patient leg. After xrays were done he notified this nurse that patient had a positive left ankle fracture with a probable left fibula fracture. Family was in in [sic] room with patient, spoke with family. On call physician when speaking earlier had stated to send patient out if xrays showed any kind of abnormalities or fracture. Family stated they would like her sent to hospital. CD made of xrays taken to send to hospital. Called non-emergent for transport. All paperwork sent to hospital with emergency staff. Patient was sent to [name of hospital omitted] per family request. Report called to [name omitted] at ER [emergency room]. Patient was administered 100mg [milligrams] of Tramadol along with 1000mg of Tylenol less than 30 mins [minutes] before transport got to pick her up. Emergency staff had to administer 100 mg of Fentalyl [sic] to attempt to transfer patient to stretcher. Patient was screaming out in pain, even with entire leg placed in air boot and supported. Family meeting patient at hospital. g. On 9/10/23 at 5:36 PM, the note documented, Received xray results back showing arthritis of left hip, minimal arthritic and chondromalacia changes of left knee, normal left lower extremity and a small posterior cancaneal spur of left foot. This is contraindicating from results verbally given while technician was in building. CD of xrays was sent to emergency room. Will wait for their radiologist to read, patient is currently in ER awaiting treatment. h. On 9/10/23 at 10:25 PM, the note documented, Res [resident] returned to facility at 2200 [10:00 PM]. Report rec'd [received] from daughter. No report from hospital and hospital called EMS [emergency medical services] for transport w/o [without] checking with facility for transportation options. Per daughter, res rec'd Oxycodone at 2130 [9:30 PM] for pain. Fracture boot to left leg/ankle. Script for Oxycodone 5mg PRN Q6 [every 6] hours for pain. Script faxed to pharmacy. Will Monitor. i. On 9/11/23 at 4:00 PM, the note documented, Pt [patient] had fall 9/10/23 with fracture of left ankle and pulled ligaments in left knee. She has been in bed today. Pain medication administered as needed as patient showed s/s [signs and symptoms] or verbalized pain. Boot in place on left lower extremity. No adverse reaction to increase in Tramadol or use of Oxycodone. Nurse Practicioner was notified of patient status and addressed issues. Appointment for Orthopedist has been scheduled today. Continue to watch patient closely and keep patient out of pain and comfortable as possible. Resident 66's incident reports revealed: a. On 3/3/23 at 6:40 PM, the report documented, Pt found on laying on the floor on the left side of the bed. Her head was facing towards the foot of her bed. She was laying on her right side. Pt did not use her call bell to get assistance. Pt was assessed for any injuries. Pt had her socks on her feet. Pt stated she got up to go to the bathroom. The report documented no injuries were noted. Pt denied hitting her head and denied any pain. Notifications made to PA [Physician Assistant] and DON [Director of Nursing}. Fall precautions [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia without behavioral disturbance, fracture of head and neck of right femur, orthopedic aftercare, encephalopathy, essential hypertension, anxiety, sepsis, and urinary tract infection. On 11/15/21 at 9:59 AM, an observation was made of resident 10 lying in bed with a family member sitting at the bedside. Resident 10 only smiled and did not answer questions directed at her. An interview was conducted with Resident 10's family member (FM). The FM stated the facility did not listen to the family's concerns about resident 10 having a UTI and that resident 10 was recently hospitalized with an infection in her blood. The FM stated resident 10 became unresponsive and that was the only reason they sent her to the hospital. The FM stated resident 10 had a history of UTI's and sepsis. The FM stated the facility would not listen to the family members when they asked for the resident's care to be improved. On 11/15/21, resident 10's medical record was reviewed. Resident 10 had a care plan focus created on 3/3/21, that revealed the resident had a potential for the following: a. bladder incontinence related to dementia b. history of UTI c. neurogenic disorder d. physical limitations e. impaired mobility Resident 10 had a care plan goal created on 3/3/21 with a target date of 3/25/21, that septicemia (blood infection) would be minimized/prevented via prompt recognition and treatment of symptoms of a UTI. The following care plan interventions were initiated on 3/3/21, and still in place at the time of the survey for resident 10 to attain that goal: a. monitor for signs and symptoms (s/sx) of discomfort on urination and frequency. b. provide assistance with toileting and toilet hygiene as needed. c. report to medical doctor any decline in incontinence. d. weekly and PRN skin evaluations. e. Monitor/document for s/sx of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. A quarterly MDS assessment dated [DATE], revealed resident 10 was always incontinent of urine and stool and required a 2 person physical assist for toilet use and hygiene cares. On 10/12/21, a Progress Note revealed the PA was notified of resident 10 being slow to respond. The PA ordered lab testing to include a complete blood count (CBC), complete metabolic panel (CMP), thyroid stimulating hormone (TSH) with reflex, a lipid panel, a glycated hemoglobin (A1C), and a vitamin D level to be drawn on 10/13/21. On 10/13/21, a Social Work Note revealed resident was in bed watching television, social worker assisted resident to eat some of her meal. This has been her baseline since arriving to our facility. No documentation was located within the progress notes of lab testing being drawn on 10/13/21, as ordered by the PA. The lab process checklist filled out on 10/12/21, by the nursing staff revealed the CBC, CMP, TSH with reflex, lipid panel, A1C, and vitamin D level were ordered to be drawn on 10/13/21. The lab requisition sheet filled out on 10/13/21, revealed that the CBC, CMP, TSH with reflex, lipid panel, A1C, and vitamin D level were not drawn until 10/14/21. The lab process checklist in the second section titled TO BE COMPLETED ONCE LAB RESULTS HAVE BEEN RECEIVED: revealed the lab results were received on 10/15/21. The sheet revealed If the lab results are critical, contact the provider. [Note: No documentation was located indicating the provider had been contacted with resident 10's lab results 10/15/21.] On 10/16/21 at 11:41 AM, a Nurses note revealed that resident 10 was not feeling well, will only respond with nodding her head yes and no. Vital signs taken blood pressure (BP) 78/57, heart rate (HR) 105, oxygen saturation (O2 sats) 88% on 2 liters (L) of oxygen. Oxygen increased to 3L by nasal cannula. Resident 10 will remain in bed, will reassess later. On 10/16/21 at 3:55 PM, a Nurses Note revealed that resident 10 had been increasingly sleepy and lethargic today. Vital signs at 3:10 PM were BP 92/33, HR 85, O2 sats 91% on 2 L. Found lab results from CMP and CBC drawn on 10/14/21. Labs had critical values. Sodium 154, BUN 122, creatinine 1.71, chloride 112 and hematocrit 47.2. Called on-call provider who ordered a peripheral intravenous (IV) line to administer 2 L of dextrose 5% in water (D5W) at 500 milliliters (ml)/hour (hr) today. Then tomorrow administer 1 L of D5W at 500 ml/hr. Repeat basic metabolic panel on 10/18/21. Attempted to place peripheral IV was unsuccessful. Contacted outside IV line placement resource to come as soon as possible. The October 2021 Medication Administration Record revealed that 1 L of D5W IV fluid was given to resident 10 on 10/16/21 at 6:37 PM, and 1 L of D5W IV fluid was given to resident 10 at 7:23 PM. On 10/17/21 at 6:17 AM, resident 10 was given 1 L D5W. On 10/17/21 at 11:46 PM, an Alert Charting Progress note revealed resident 10 tolerated 3 L of D5W well, although continues to have low BP. Medical Doctor (MD) notified. On 10/18/21 at 12:10 PM, a Nurses Note revealed the PA ordered to send resident 10 to the ER for evaluation and treatment due to increased lethargy and disorientation. Resident 10's BP was 68/38, resident 10 had projective vomit before emergency transport arrived. Family wanted resident 10 sent to the ER. On 10/18/21 at 11:43 AM, a transfer record revealed resident 10 was transferred to a local hospital for further evaluation and treatment. [Note: This was 6 days after the labs were ordered to be drawn to evaluate resident 10's change in status on 10/12/21.] On 10/18/21 at 5:07 PM, a history and physical revealed resident 10 was admitted to the local hospital for septic shock, UTI, and acute renal failure On 11/17/21 at 2:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated all critical lab values were called to the PA or there was an on call PA. LPN 1 stated the hospital was not always good about getting the lab results back to the facility, so the staff would call and get them. LPN 1 stated if the lab values were critical then the hospital was better at getting them to the facility. LPN 1 stated if there was a critical lab value then the staff would call the PA, or use the text messaging system to send out to the administration and the manager. LPN 1 stated lab values were kept in the electronic medical record and the paper chart. LPN 1 stated they were supposed to make a progress note in the medical record then scan it and put it in the paper chart. LPN 1 stated lab results were expected the same day they were drawn, urgent labs (STAT) were expected within hours of when they were drawn. On 11/17/21 at 3:00 PM, an interview was conducted with LPN 3. LPN 3 stated the lab process checklist was completed in order to follow through with labs and to ensure nothing got missed, the checklist stays in the blue folder at the desk until it was finished and marked off, then it goes to the unit manager. LPN 3 stated if lab values were critical the nursing staff got a hold of the MD right away. On 11/17/21 at 3:04 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated when she received the lab process checklist, lab requisition, and lab results she checked them and made sure they were put in the chart and recorded. UM 1 stated the lab results were then scanned into the electronic medical record. UM 1 stated the requisition and the lab process checklist were kept in the binder in the UM office. UM 1 stated there was a delay in treatment for resident 10, the nurses did not communicate well and the labs were missed and care was delayed. On 11/18/21 at 9:00 AM, a follow up interview was conducted with LPN 1. LPN 1 stated the lab checklist had been in place for at least 4 to 5 months. LPN 1 stated the process had been in place for quite some time but was unable to quantify the exact amount of time. On 11/18/21 at 9:15 AM, a follow up interview was conducted with the UM 1. UM 1 stated that resident 10 having to be sent to the hospital was unfortunate and possibly a result of a miscommunication between the day nurse and the night nurse. UM 1 stated the day nurse placed the lab paperwork in the provider bin and did not review the lab values. UM 1 stated the night nurse received report that the labs were drawn but nothing was done. UM 1 stated the lab checklist was put on paper in June of 2021 but has been a process at the facility for a long time, it started when a resident needed dialysis and did not receive it. UM 1 stated she was the developer of the lab process checklist. UM 1 stated resident 10 should have been dealt with sooner, there was a delay in treatment. UM 1 stated she was unsure if the delay in treatment would have changed the outcome but it did not make the situation or resident 10 better. UM 1 stated it was expected of the nursing staff to assess the residents and call the PA if needed. UM 1 stated the nurses all have the skills and equipment to draw blood for labs and start IV therapy if needed. UM 1 stated resident 10's veins were quite small and the nurse was unable to obtain an IV access. UM 1 stated the nursing staff did not try to draw blood. UM 1 stated she was in the facility the day the blood was needed and could have drawn the labs but no one made her aware of the need. UM 1 stated an outside service was called to come in, sometimes they do not come in when we ask them to, this instance they came when they could. UM 1 stated the nursing staff should have assessed resident 10 and determined that waiting was not in the best care for resident 10 and called the provider for further instructions or to send resident 10 to the ER. UM 1 stated the staff were educated monthly on how to assess residents and how to care for abnormal assessments. UM 1 stated the lab did not call the facility to make them aware of the critical lab values but it was ultimately the nursing staff and facilities responsibility to check for the labs and care for the residents. On 11/18/21 at 10:20 AM, an interview was conducted with the PA. The PA stated the facility would let her know about resident needs or abnormal labs via text messaging or by a phone call for a critical value or an urgent need. The PA stated if there was a critical lab then she would like the staff to call her, I do not want things to slip through the cracks. The PA stated there was a provider available 24 hours a day every day of the week and the providers can do a Telemed visit if needed. The PA stated the expectation from the providers was to send a resident to the ER and not wait for the out sourced therapy company to come draw labs or start an IV if the resident was in a bad condition. The PA stated that way the resident could get stabilized and treatment was not delayed. The PA stated that the out sourced company used by the facility for labs and IV therapy was not STAT. The PA stated the nursing staff should all be able to draw blood and start IV's. The PA stated she wished there were skills labs available to the staff to update those skills. The PA stated I hate to hear, let me call the PICC (peripherally inserted central catheter) nurse to start that IV. On 11/18/21 at 11:58 AM, an interview was conducted with the DON. The DON stated labs were drawn by MD order, the labs were put in the electronic medical record, on the lab requisition sheet, added to the calendar, and we keep the lab requisition open so both shifts can see it. The DON stated they have the checklist so that it was a step by step process. The DON stated if there was an abnormal assessment the nursing staff should let the PA or the provider know immediately and follow the orders given. The DON stated if the medical condition warrants the resident to be sent to the hospital then the staff need to send them. The DON stated the nurses were expected to draw blood when labs were needed, especially when they were STAT labs. The DON stated when STAT labs were drawn by the nursing staff, the facility would call the lab company to come pick up the labs and take them to the hospital. The DON stated the lab would then let them know the results and the nursing staff would make the provider aware. The DON stated the turn around time for this was about 4 to 8 hours for STAT labs and 24 hours for routine labs. The DON stated STAT labs were known to be STAT because they would call the out sourced lab to have them come pick them up, the nursing staff should mark the labs as STAT on the sheet but if it was not marked the lab would still be expected as STAT if the courier was called to come get them. The DON stated the expectation of the nursing staff by the administration was to let the provider know if the lab results were not within normal limits. The DON stated her expectation would have been for the nurses to send resident 10 to the ER and not wait for the outside IV therapy service to come in and start the IV. The DON stated there was a break in the system and we need to educate the nurses on judgement, when to send the resident to the hospital, and how to get the resident the treatment they need right away. Based on observation, interview, and record review it was determined the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 2 out of 23 sampled residents, a resident with a change of condition had a delay in treatment. In addition, a resident that was transferred improperly sustained a fracture. Resident identifiers: 10 and 55. Findings include: 1. Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to displaced fracture of base of neck of left femur subsequent encounter for closed fracture with routine healing, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acute kidney failure, hypotension, essential hypertension. anxiety disorder, and insomnia. On 11/15/21 at 2:29 PM, an interview was conducted with resident 55. Resident 55 stated that her leg was fractured when the Certified Nursing Assistants (CNAs) transferred her wrong. Resident 55 stated she had weakness on her left side and she was trying to tell the CNAs how to transfer her but they would not listen. Resident 55 stated she was transferred to the hospital and now she had to wear a brace. Resident 55's medical record was reviewed on 11/16/21. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented resident 55 as requiring extensive assistance of two plus persons for transfers. A care plan focus initiated on 7/5/21, documented Activities of daily living (ADL) / Level of Assistance Required on admission and adaptive equipment used: 2 Person supportive assist, Extensive, Wheelchair (Manual or electric). A care plan goal initiated on 7/5/21 and revised on 11/10/21, documented I will have no decrease in my current mobility status during my stay. and I will have no falls during my stay. Interventions initiated on 7/5/21, included the following: a. Encourage as much independence as possible. b. Praise all efforts of self care. c. Provide any adaptive equipment needed to assist me with obtaining my independence with my adls: Trapeze, Cane, Slide board, Walker, Brace, Bed rails, Wheelchair, etc. d. Staff to assist with adl's and mobility as needed. e. Therapies to evaluate and treat as ordered. On 10/17/21 at 8:35 AM, a Nurses Note documented Staff member reported pt (patient) is (sic) stated she was transferred incorrectly and that her L (left) knee is painful. Upon assessment, swelling just superior to L knee noted on lateral side. Pt stated she has been applying ice pack. Pt stated she specifically instructed CNAs to not turn her to the right upon transfer. Pt stated CNAs did anyway. Pt reported 11 out of 10 pain. On-call notified. X ray 2V (2 view) ordered of L knee, and Tramadol scheduled q (every) 4 hours x 7 days, per [name of physician]. On 10/17/21 at 9:45 AM, a Nurses Note documented Received notification from on-call physician, [name of physician], that Tramadol order has been changed to PRN (as needed) rather than scheduled. Per pt's husband request, on-call physician ordered pt to be sent to ER (emergency room) for evaluation and to r/o (rule out) fx (fracture). On 10/17/21 at 2:10 PM, a Nurses Note documented Per [name of local hospital] staff, pt has been admitted to [name of local hospital] for surgery r/t (related to) L hip fx. Received a phone call from pt's spouse. Pt's husband kindly asked for staff to be educated on the importance of respecting pt's instructions during a transfer. On 10/17/21 at 6:38 PM, a Nurses Note documented At report, NOC (night) nurse stated at 0530 (5:30 AM) ice pack was applied to pt's L knee and PRN Tylenol was administered. Staff member reported to me pt stated she was transferred incorrectly on NOC shift, and that pt is reporting pain in L knee. NOC staff member reported that pt was turned counter-clockwise, according to pt's instruction. Upon assessment, swelling just superior to L knee noted on lateral side. Pt stated she has been applying ice pack. Pt stated she specifically instructed staff to not turn her to the right upon transfer. Pt stated CNAs did anyway. Pt heard a crack during transfer. Pt requested another order for pain medication d/t (due to) 11 out of 10 pain. INTERVENTION: Left message with on-call physician. On-call physician, [name of physician], X ray 2V ordered of L knee. Regarding pt's need for pain medication, pt has a hx (history) of AKI (acute kidney injury). Tramadol scheduled q 4 hours PO (by mouth) 50 mg (milligrams) x 7 days. Received notification from on-call physician, [name of physician], that Tramadol order is to be changed to PRN Tramadol PO 50 mg x7 days rather than scheduled. PRN Tramadol administered. Per pt's husband request, on-call physician ordered pt to be sent to ER for evaluation and to r/o fx. Per [name of physician], afternoon and evening doses of scheduled Tramadol d/c'd (discontinued). On 10/17/21 at 10:16 AM, the local hospital History and Physical documented a x-ray imaging result of the left tibia and fibula. The impression documented an old fibular head and proximal tibial fractures. No acute fracture identified. On 10/17/21 at 10:46 AM, the local hospital History and Physical documented a x-ray imaging result of the left femur two views. The impression documented a displaced left femoral neck fracture. On 10/17/21, the local hospital Progress Note documented that resident 55 presented today for a displaced left femoral neck fracture. Orthopedics was concerned about the acuteness of resident 55's injury and resident 55 would undergo a computed tomography (CT) scan for further clarification. On 10/17/21 at 12:57 PM, the local hospital Progress Note documented a CT of the left hip was obtained and the impression documented a displaced femoral neck fracture which appears to be chronic and may be a pathologic fracture as there appears to be soft tissue mass in the fracture plane. Evaluation was suggested. On 10/18/21 at 8:57 AM, the local hospital Progress Note documented a CT of the left knee was obtained and the findings documented a lipohemarthrosis to the left knee. Diffuse osseous demineralization was present. No displacement of the articular surfaces of the knee joint. There was a fracture involving the anterior margin of the medial femoral condyle best seen on the axial images. The impression documented there was a nondisplaced acute intra-articular fracture involving the medial femoral condyle. On 10/21/21 at 5:55 PM, an admission Summary documented Resident readmitted in a stretcher for UTI (urinary tract infection) and L tibia fracture that has immobilized. History includes hemiplegia and hemiparesis following cerebral infarction, anxiety, insomnia, ESBL (extended spectrum beta-lactamase) resistance, and HTN (hypertension). brace on L leg, 2 persons assist with bed mobility and transfers, redness under R (right) breast, wound in coccyx, pain level 7/10 in L leg and pain med (medications) administered as ordered, . On 10/22/21 at 7:26 PM, a Physician Progress Note documented 10/22/2021: PA (Physician Assistant) Initial Visit s/p (status post) Hospital Stay - Pt in PT (physical therapy), pleasant, no acute distress, AOx4 (alert and oriented to person, time, place, and situation), VS (vital signs) WNL (within normal limits). 'I'm alright.' Pt was recently in the hospital for a sudden sharp pain in L hip after transferring from wheelchair to bed in facility. Pt was noted to have a fibular head and proximal tibial fracture, old vs acute was noted in hospital H/P (history and physical). Pt notes pain is controlled. Denies any acute sxs (signs or symptoms) or illness. Recommend getting DEXA (Dual-energy X-ray absorptiometry) scan in the future to screen for osteoporosis. Patient agrees to screening. Will continue to monitor. On 10/25/21 at 5:34 PM, a Nurses Note documented Spoke with [name of PA] on phone. She would like to get the patient a DEXA scan to check for osteoporosis. Pt has had recent broken bones. Filled out transportation/appt (appointment) sheet for appointment to be scheduled. On 10/26/21 at 11:26 AM, a New Order Note documented Patient is a 2-person transfer. Please have CNAs communicate with PT team during the week if they need to be educated on how to transfer patient properly. On 10/26/21 at 11:28 AM, a New Order Note documented Keep left leg extended when transferring patient or repositioning patient in bed. On 10/29/21 at 4:23 PM, a New Order Note documented Per Orthopedic Surgeon [name of surgeon on 10/28/21, continue minimal weight bearing LLE (left lower extremity) for four weeks. Pt is to be up in wheelchair at least once per shift. On 11/16/21 at 11:47 AM, an interview was conducted with resident 55. Resident 55 stated that two CNAs were transferring her at the time of the incident. Resident 55 stated it was approximately 3:00 AM, and she had to use the restroom really bad. Resident 55 stated she can only assist during transfers with her right side due to a stroke. Resident 55 stated the CNAs transferred her on left side twisting her left leg and she heard two pops. On 11/16/21 at 11:52 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated when she came on shift the night nurse reported that resident 55 was having pain in her knee and an ice pack and Tylenol were given to resident 55. RN 2 stated that after she was finished counting the narcotic medications with the night nurse the day shift CNAs reported that resident 55 was in a lot of pain. RN 2 further stated the day shift CNAs reported that resident 55 had instructed the nightshift CNAs to turn her to the right during transfer and the CNAs did not listen to her. RN 2 stated she asked resident 55 about her pain and resident 55 stated she was still in a lot of pain. RN 2 stated she called the on call doctor and the doctor would not order any narcotics for resident 55 until the X-ray results came back. RN 2 stated resident 55's husband was at the facility and questioned when the X-ray was going to be at the facility. RN 2 stated she was unsure when the X-ray technician would arrive but the X-ray had been ordered. RN 2 stated resident 55's husband requested that resident 55 be sent to the ER. RN 2 stated resident 55 complained of left knee pain but no hip pain. RN 2 stated she had reported the incident to the Director of Nursing (DON) and the PA. On 11/16/21 at 12:01 PM, an interview was conducted with CNAs 2. CNAs 2 stated when she reported to the floor to start her shift resident 55 had her call light on and asked her to remove the ice pack. CNAs 2 stated she asked resident 55 what happened and resident 55 reported when the night shift CNAs transferred her to the bathroom she heard a pop in her knee. CNAs 2 stated the night nurse reported the CNAs took resident 55 to the bathroom at 3:00 AM and nothing had been reported to him regarding the incident. CNAs 2 stated she had sent a message to CNAs 3 to find out what had happened. CNAs 2 stated that CNAs 3 reported they did everything resident 55 asked them to do and pivoted resident 55 on her left leg. CNAs 2 stated the right leg was resident 55's strong leg. CNAs 2 stated that CNAs 3 reported resident 55 complained her knee was hurting and she forgot to report the incident to the nurse. CNAs 2 stated resident 55 was a two person transfer because she could not use her left leg. On 11/16/21 at 1:57 PM, an interview was conducted with RN 4. RN 4 stated he was not notified of anything unusual regarding resident 55 the day of the incident. RN 4 stated when he came back to the facility to work his next shift he was notified that resident 55 had a fracture from the CNAs moving her improperly. RN 4 stated resident 55 had complained of knee pain frequently and he would put Voltaren Gel on resident 55's knee. [Note: Out of 51 opportunities resident 55 received the Voltaren Gel on 7 occasions for the month of October 2021.] On 11/17/21 at 11:07 AM, an interview was conducted with CNAs 4. CNAs 4 stated resident 55 required three CNAs to transfer. CNAs 4 stated resident 55's wheelchair was positioned at the head of the bed for transfers. CNAs 4 stated two CNAs were positioned under resident 55's arms holding the pants and the third CNAs would hold the injured leg. CNAs 4 stated that two CNAs were required to transfer resident 55 prior to the injury. On 11/17/21 at 11:13 AM, an observation was conducted of CNAs 4, CNAs 5, and CNAs 6 transferring resident 55 from her bed to wheelchair. CNAs 4 positioned the wheelchair at the head of the bed with the seat area of the wheelchair positioned to face the foot end of the bed. CNAs 5 was positioned at resident 55's feet and CNAs 4 and CNAs 6 were positioned at resident 55's head. The CNAs in unison positioned resident 55 to a sitting position at the side of the bed. CNAs 4 and CNAs 6 positioned their arms under resident 55's arms holding her pants and CNAs 5 stabilized resident 55's left leg. In unison the CNAs positioned resident 55 to a standing position with resident 55's left leg stabilized and straight. Resident 55 was able to stand and bear weight on the right leg with maximum assist from the CNAs. The CNAs in unison pivoted resident 55 on her right foot and resident 55 was able to sit in the wheelchair. On 11/17/21 at 11:25 AM, an interview was conducted with resident 55. Resident 55 stated on the day of the injury the CNAs placed the wheelchair at the foot of her bed with the seat opening facing the head of her bed. Resident 55 stated when the CNAs stood her up she was pivoted towards her left side to the wheelchair and her left leg twisted underneath her. On 11/17/21 at 12:22 PM, an interview was conducted with the DON. The DON stated the day nurse received report that during the transfer resident 55 had a fracture or heard something pop. The DON stated she had reached out to the CNAs that were assisting with the transfer and the way she understood the CNAs did everything that resident 55 told them to do and the CNAs did not hear anything pop but resident 55 had. The DON stated resident 55 had complained of pain and the nurse gave her an ice pack and Tylenol and reached out to the Medical Director for a X-ray. The DON stated both CNAs were standing on each side of resident 55 to help with the transfer. The DON stated the CNAs had not worked with resident 55 before so they asked resident 55 for specific instructions on transferring. The DON stated she had reported the incident to the Administration and Cooperate Nurse and in the mean time she was trying to find out exactly what had happened. The DON was asked if the CNAs had been trained on resident transfers. The DON stated the CNAs would give report to each other every shift on instructions regarding the residents. The DON stated the CNAs would try to follow the instructions per the resident. On 11/17/21 at 1:00 PM, an interview was conducted with CNAs 3. CNAs 3 stated she worked night shift. CNAs 3 stated resident 55 wanted to get out of bed and she usually did not get out of bed at night. CNAs 3 stated she had never transferred resident 55 before and had asked resident 55 how to transfer her. CNAs 3 stated she had positioned the wheelchair at the foot of resident 55's bed. CNAs 3 stated if facing resident 55's bed the wheelchair was positioned to the right. CNAs 3 stated she had not realized the wheelchair was positioned for getting resident 55 into bed because resident 55's right side was her strong side. CNAs 3 stated when they transferred resident 55 the resident reported that something had popped and complained of knee pain. CNAs 3 stated she had asked resident 55 if she would still like to go to the bathroom and resident 55 stated yes. CNAs 3 stated when resident 55 was finished with the bathroom they transferred resident 55 back to bed without incident. CNAs 3 stated she had reported the incident to the nurse on shift, RN 4, that resident 55 was having pain because resident 55 had heard something pop, and was requesting a pain pill.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 out of 25 sampled residents, that the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise. Specifically, a resident lost 33% or 100 pounds of weight within 4 months of being at the facility and received a feeding tube. While the resident had the feeding tube, a physician's order for flushes was not followed resulting in the resident's sodium trending down to 126 and receiving lasix. Resident identifier: 32. Findings include: Resident 32 was admitted to the facility initially on 1/25/19 and readmitted on [DATE] with diagnoses which included heart failure, acute kidney failure, hypertension, anxiety, depression, hypothyroidism, obesity, and weakness. On 8/12/19 at 12:19 PM, an interview was conducted with resident 32. Resident 32 stated that she had lost 100 pounds since admit. Resident 32 stated that the weight loss was not planned or wanted. Resident 32 stated that she was so sick that she was not able to eat. On 8/13/19, resident 32's medical record was reviewed. Resident 32 was at the hospital prior to being admitted to the facility. The hospital records contained the following progress notes: a. On 1/22/19 at 11:59 AM, a Hospital progress note documented, This is a [AGE] year old female brought in by EMS (emergency medical services) because of increasing weakness, nausea and lower extremity problems. Patient apparently in the last day or to (sic) call her primary care physician because of difficulty eating, drinking and nauseous (sic) she's had for 3 weeks. She is becoming dehydrated. He (sic) is (sic) also had some diarrhea and has tried imodium without much success. She also had some incontinence and is fairly immobile. b. On 1/22/19 at 2:59 PM, a Hospital Progress note documented, [AGE] year old female who presents .with issues of generalized weakness in the setting of prolonged watery loose stools .Patient's history dates back approximately 4 weeks where she developed loose stools, they have been described as watery and somewhat progressive in nature .she's had some associated nausea without vomiting .Patient also reports she's had some difficulty swallowing foods she denies any odynophagia. She also feels like she is losing muscle mass. Over the course of this prolonged diarrheal episode she reports she's been getting progressively weekend (sic) and she is now unable to ambulate, she reports she's exhausted with any attempted movement .It is noteworthy that her weight is approximately 160 kg (kilograms) (352 pounds) her last admission in spring she was 180 kg (396 pounds). [Note: this was a loss of 56 pounds or a 12% weight loss between the two admissions.] c. On 1/22/19 at 3:19 PM, the patient appears dehydrated with dry mucous membranes, her weight is well below baseline She also reports dysphagia plan for swallow evaluation . d. On 1/24/19 at 10:06 AM, a Hospital progress note documented, [AGE] year old female admitted on [DATE] for prolonged episodes of diarrhea in the setting of acute renal failure .Additionally patient has had intermittent hypoglycemia and poor by mouth intake may have component of protein calorie malnutrition-prealbumin is pending and the patient's blood pressures have been sluggish this morning adding albumin infusing, holding antihypertensives and continuing a dextrose drip overnight. Overall the patient is quite deconditioned and malnourished in the setting of morbid obesity Patient does have morbid obesity but I feel the patient does have clinical signs of protein calorie malnutrition given the mild temporal wasting noted she also reports quite a bit of weight loss. A lot of this weight loss may be related to improvement in her edema since last admission . Resident 32's weight trends were reviewed and revealed the following: [Note: all weights are in pounds unless otherwise indicated.] a. At the hospital on 1/22/19, prior to admit to the facility, resident 32's weight was documented as 347. b. On 1/25/19, 328 [Note: This was the first weight documented at the facility.] c . On 1/28/19, 327 d. On 2/1/19, 325 e. On 2/19/19, 312 f. On 3/5/19, 294 [Note: From admit weight of 328, this was an 11% weight loss in 5 and a half weeks.] g. On 3/26/19, 267 [Note: From the last weight on 3/5/19 of 294, this was a 10% weight loss in 2 weeks.] h. On 4/9/19, 254 [Note: This was a 23% weight loss in 2 and a half months.] i. On 4/16/19, 245 j. On 5/28/19, 222 [Note: This was a 33% weight loss in 4 months.] k. On 6/14/19, 231 l. On 6/17/19, 218 m. On 7/8/19, 220 n. On 7/15/19, 222 The following nursing progress notes, dietary progress notes, lab results, and physician's orders were identified: a. On 1/27/19 at 9:45 PM, a Nursing note documented, Patient complains of nausea. Patient denies vomiting. Zofran administered as prescribed for nausea with effective results. Nausea subsided. b. On 1/28/19, a nutrition assessment was completed by the dietary technician. Resident 32's weight at the time of the assessment was 328 pounds. Resident 32's adjusted body weight was calculated to be 194 pounds or 88 kilograms. Resident 32's calorie needs were estimated to be 2205-2645 Calories/day. The factor used to calculate this was 25-30 calories per kilogram. Resident 32's protein needs were estimated to be 88 grams. The factor used to calculate this was 1.0 grams per kilogram. It was documented at that time that the resident leaves 25% plus at most meals. The nutrition note stated Nutritional concerns include swallowing difficulty, mechanically altered diet, morbid obesity and low intake. Pt (patient) says appetite is slowly improving. She had boost w/ (with) every meal in the hospital and wants to continue that here. Rec (recommend): Ensure TID (three times a day) with meals. c. On 1/29/19 at 10:50 AM, a Nursing note documented, Patient and family met for IDT (interdisciplinary team meeting). They are concerned about patient's lack of intake and patient's aversion to food. Educated on appetite stimulants. Pt would like stool softener scheduled as well. Pt to meet with ST (speech therapy) for eval (evaluation). Notified MD (Medical Doctor) of patient concerns. all questions answered. WCTM (will continue to monitor). [Note: No appetite stimulant was added at this time.] d. On 1/29/19 at 3:17 PM, a Nutrition note documented, Poor appetite. PO (by mouth) intake of 18%. Rec: Ensure TID per pt request. e. On 1/29/19 at 5:00 PM, a Physician's order for Ensure three times a day was put in place. f. On 1/30/19 at 2:58 PM, a Physician's progress note documented, She had episodes of hypoglycemia during her hospitalization required dextrose infusion in addition to her IV (intravenous) fluids resuscitation. However today, she had stability in her blood work, and her oral intake has improved significantly without any symptoms. [Note: resident 32's recorded meal intake at this time averaged 13% since admit on 1/25/19.] g. On 2/9/19, a Physician's progress note documented, PO intake improving gradually with Ensure and fruit. [Note: Meal intakes between 1/30/19 to 2/9/19 were documented to average 9.5%.] h. On 2/20/19 at 3:19 PM, Order by [name withheld] PA (Physician's Assistant) for a dietary consult to discuss magic cups and other dietary changes. i. On 2/21/19, The dietary consult was completed and stated the following: .eating 7%. Eating [approximately] 75% Ensure TID. Reconsider appetite stimulant or TF (tube feeding). Add to NAR (nutrition at risk) discussion. [Note: no other supplement or dietary changes were made.] j. On 2/22/19, On a dietary recommendation form, the request for an appetite stimulant or tube feedings was declined by the physician. The response from the physician was schedule nausea meds (medications) first. At that time, resident 32 had Zofran ordered for 4 milligrams (mg) every 6 hours as needed. An order was written in addition to the as needed dose of scheduled Zofran 4 mg 4 times per day. k. On 2/22/19, Resident 32 was discussed at the NAR meeting. The NAR meeting identified that the resident was consuming about 7% of meals related to nausea, vomiting and decreased appetite. The intervention added was to increase Ensure to 4 times per day. l. On 2/22/19 at 5:15 PM, a Nursing note documented, per dietary recommendations increase Ensure to 4 times per day in between meals d/t (due to) decreased appetite eating 7% of meals. WCTM. [Note: documented meal intakes between 2/10/19 to 2/25/19 averaged 4.7%.] m. On 2/27/19 at 1:49 PM, A Physician's Progress Note documented, She complains of some occasional nausea. n. On 2/28/19 at 3:39 PM, a Nursing note documented, Patient complains of nausea. Patient denies vomiting. Zofran effective. o. On 3/2/19 at 4:06 PM, a Nursing note documented, Patient complains of nausea. Vomiting present. Zofran given pt reports it was effective. p. On 3/6/19 at 2:54 PM, a Physician's Progress Note documented, Nausea, continue Zofran when necessary q. On 3/6/19, a Nutrition note documented, PO intake of Reg/NDD2 (regular, national dysphagia diet level 2) is 2%. Pt receives ensure 4 [times per] day. [Percent] intake (of ensure) not recorded in [name of electronic medical record software]. Pt says they bring her ensure 4 [times] but she is only able to drink 1 1/2 per day. Pt is still experiencing extreme nausea. Nurses have scheduled zofran for pt 4 [times per] day rather than as needed. Pt tried to eat jello but was unable to keep it down. She says she is hungry and is doing as much as she can to eat. No recs (recommendations) at this time. Will discuss in NAR. The nutrition assessment indicated that resident 32 was not meeting her nutritional needs with her current intake. r. On 3/8/19, Resident 32 was reviewed at the NAR meeting. Resident 32 was triggered for a weight loss of -5.6% x 1 week related to nausea and vomiting. No interventions were implemented. The decision was to CTM or continue to monitor. [Note: Resident 32's weight was 294.8 pounds at time of this meeting. This was an 11% weight loss x 5 weeks. Meal intakes were 2%. According to the American Society of Parenteral and Enteral Nutrition, Resident 32 would have qualified for severe malnutrition at this time.] s. On 3/8/19 at 3:31 PM, a Physician's progress note documented, Nausea, continue Zofran when necessary, GI (gastrointestinal) consult for persistent unexplained nausea. [Note: This was six weeks after resident 32 was admitted to the facility.] [Note: documented meal intakes between 2/26/19 to 3/13/19 averaged 4.2%.] t. On 3/18/19 at 12:25 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. pt is given Zofran before meals. Pt eats small amount of food due to nausea. u. On 3/20/19 at 6:50 PM, Patient has constipation. Patient complains of nausea. Patient denies vomiting. pt is given Zofran before meals. Pt eats small amount of food due to nausea. v. On 3/21/19 at 12:04 AM, Patient has constipation. Patient complains of nausea. Patient denies vomiting. pt is given Zofran before meals. Pt eats small amount of food due to nausea. w. On 3/23/19 at 3:21 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Scheduled zofran before meals. [Note: On 3/26/19, resident 32's weight was taken and measured at 267 pounds. This was a 10% loss in 2 weeks, since her weight taken on 3/6/19 was 294 pounds. This was a significant weight change. Resident 32 was not reviewed again at a NAR meeting until 4/19/19.] x. On 3/28/19 at 1:02 PM, a Social work note documented, SSW (Social Service Worker) spoke with [family member] via phone today. [Family member] is very worried about patient [Family member] reported to SSW that patient was still vomiting-nursing notes reflect otherwise. [Family member] is wondering about GI consult. y. On 3/28/19 at 3:32 PM, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Scheduled Zofran before meals. [Note: documented meal intakes from 3/14/19 to 3/29/19 averaged 2.27%] z. On 3/29/19, A NAR meeting was triggered due to resident's weight trend down 9% in 1 month. Resident was at 268 pounds. The trend down was identified to be related to refusal to eat d/t stomach pain, shingles etc. The intervention was to refer to doctor. aa. On 3/29/19 at 11:50 PM, a Physician's progress note documented, been unable to really eat very well with persistent nausea and occasional vomiting .Persistent nausea and vomiting, start Reglan 5 mg daily before meals in addition to Zofran. Gastrointestinal specialist for further investigation of her persistent nausea and vomiting and poor appetite. Poor appetite, start cyproheptadine 2 mg 4 times a day. [Note: The physician had also recommended a GI consult in a progress note dated 3/8/19.] bb. On 4/1/19 at 1:02 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Scheduled Zofran and Reglan before meals. Pt reports effective. Pt reports constipation, Miralax given. cc. On 4/1/19 at 5:06 PM, a Physician's progress note documented, Persistent nausea and vomiting resolved. Continue Reglan 5 mg daily before meals in addition to Zofran as needed . Poor appetite, continue cyproheptadine 2 mg 4 times a day. dd. On 4/5/19 at 6:34 PM, a Nursing Note documented, pt weak and groggy today, difficulty staying awake. Decreased edema to all extremities, decreased redness to BLE (bilateral lower extremities), pt worked with PT/OT (physical therapy and occupational therapy) today which she reports made her tired. Poor appetite only drinking sips of ensure . ee. On 4/8/19 at 12:57 PM, a Physician's progress note documented, She complains of nausea, vomiting and constipation with hemorrhoids Persistent nausea and vomiting, bruit on the Reglan, we'll see GI later this week . Poor appetite, start cyproheptadine 2 mg 4 times a day. ff. On 4/8/19 at 1:55 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Scheduled Zofran and Reglan before meals. gg. On 4/10/19 at 9:47 AM, a Physician's progress note documented, She reports significant improvement in her nausea since being started on the reglan . Persistent nausea and vomiting, much improved on Reglan, we will continue Reglan 3 times a day . Poor appetite, start cyproheptadine 2 mg 4 times a day hh. On 4/12/19 at 2:04 PM, a Physician's progress note documented, She reports that since we started the reglan she has not had nausea or vomiting .Persistent nausea and vomiting, much improved on Reglan, we will continue Reglan 3 times a day. Hold off on GI consult for now . Poor appetite, improving, we will increase cyproheptadine to 4 mg 4 times a day. ii. On 4/12/19 at 2:49 PM, a Nursing note documented, DC (discontinue) GI consult pt is responding well to reglan regime. jj. On 4/12/19 at 5:20 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. kk. On 4/14/19 at 3:18 PM, a Nursing note documented, Resting quietly after lunch. Denies any difficulty or adverse effects to increase in Cyproheptodine for appetite improvement. Stated 'I don't really feel that hungry or wanting food yet, but it's not making nauseated. [Note: documented meal intakes from 3/30/19 to 4/14/19 averaged 6.03%] ll. On 4/15/19 at 11:22 AM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. pt has GI consult apt (appointment) today. Will f/u (follow up) with any new orders or recommendations. mm. On 4/17/19 at 5:12 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Tol. (tolerating) Cyproheptodine well. Appetite fair. nn. On 4/17/19, a Nutrition note documented, Wt (weight) note: CBW (current body weight): 245# (pounds), Wt loss -3.8% x 1 week. PO intake of Reg/NDD2 diet is 15%. Pt receives Ensure 4x/day intake is 25%. Pt says appetite is improving and so is the nausea and constipation. she has been eating bananas, jello, oatmeal and other fruit and says she tries to drink 2 Ensures/day. Pt had a GI scheduled but canceled it because she is feeling better. Meal intake has improved slightly. No new recs at this time. CTM. oo. On 4/18/19, a note from the Dietitian read as follows: Note wt [loss] cont (continues) and poor PO intake. Res getting reglan and cyproheptadine for appetite stimulants. Note res is trying to eat more and staff encouraging resident to eat. Will follow. pp. On 4/19/19 at 1:14 PM, a Physician's progress note documented, Persistent nausea and vomiting, much improved on Reglan, we will continue Reglan 3 times a day Poor appetite, improving, continue cyproheptadine to 4m g 4 times a day. qq. On 4/19/19 at 5:00 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. rr. On 4/19/19 at 5:11 PM, a Nursing note documented, NAR NOTE: Pt lost 3.8% weight in 1 week. Pt intake has improved to 15% of meals. Pt's appetite has improved slightly. Pt reported nausea and constipation were gone and she is trying to eat more. No recs at this time. WCTM. [Note: documented meal intakes from 4/15/19 to 4/30/19 averaged 20%.] ss. On 5/1/19 at 12:47 PM, a Nursing note documented, Patient still plans to discharge to home with husband but does not feel strong enough yet. tt. On 5/7/19 at 2:10 PM, a Nursing note documented, BMP (basic metabolic panel) results: Sodium- 151 (high) . uu. On 5/8/19 at 4:18 PM, a Nursing note documented, Verbal orders received to encourage fluids every shift at least 2 liters. vv. On 5/10/19, Lab result: Sodium 151 High [Note: documented meal intakes from 4/25/19 to 5/10/19 averaged 21.4%] ww. On 5/13/19, Lab result: Sodium 154 High xx. On 5/16/19, Lab result: Sodium 156 High yy. On 5/16/19 at 3:47 PM, New Order Note: Sodium Chloride Solution 0.45 % Use 1 liter intravenously every shift for Critical high sodium of 156 Run a 75ml/hr (milliliter per hour). Start after bolus and run until 5/17/19. AND Use 1 liter intravenously one time only for critical high Sodium of 156 for 1 Day 1 liter bolus over 1 hour . zz. On 5/17/19, Lab result: Sodium 153 High aaa. On 5/19/19, Lab result: Sodium 153 High bbb. On 5/20/19 at 4:17 PM, a Nursing note documented, BMP results received with high blood sodium levels and .PA notified. New order received as follows: Sodium Chloride Solution 0.45 % Use 75 ml/hr intravenously every shift for Elevate blood sodium levels. Run continuously at 75ml/hr until Sodium level within normal range. Obtain BMP every day until sodium levels within normal range. ccc. On 5/21/19 at 3:21 PM, a Nursing note documented, New order per [physician's name withheld]: Change IV fluid to 1/2 NS (normal saline) at 125 ml/hr x 2 L (liters). Recheck BMP in am. ddd. On 5/21/19 at 3:34 PM, a Nursing note documented, Lab results: Sodium- 153, Potassium- 3.3, Chloride- 112, Glucose- 62 . eee. On 5/22/19, a Nutrition note documented, Pt has been refusing to be weighed. PO intake of Reg/NDD2 diet is 4% and ensure 4x/day is unknown. Pt last month had significant weight loss. Met w/ patient. Pt seems to be having trouble talking because of a mouth issue. Pt also reported that the regular Ensure has been making her stomach upset and she has been throwing up. Pt reported she also wants fresh fruit, chicken broth and pudding to help her appetite. Rec: D/C Ensure 4x/d (4 times per day) and Add Ensure Clear BID (twice per day) . [Note: This assessment and recommendation was completed by a dietary technician.] fff. On 5/22/19, Lab result: Sodium 152 High ggg. On 5/23/19 at 2:04 AM, a Nursing note documented, Patient c/o (complains of) N/V (nausea and vomiting) this shift. PRN (as needed) Zofran given with therapeutic results. IV 1/2 NS infusing at 125 ml (milliliters) currently, tolerating well. hhh. On 5/23/19, Lab result: Sodium 147 High iii. On 5/23/19 at 3:20 PM, a Nursing note documented, Resident reviewed in skin and weights meeting. Resident refusing ensure r/t (related to) nausea. Will replace with Ensure Clear BID. Resident refuses to get weighed and has been depressed r/t current condition. MD aware and monitoring. jjj. On 5/23/19 at 3:31 PM, a Nursing note documented, Addendum to skin and weights note. Resident has scheduled Zofran r/t nausea and has requested broths and fresh fruits for her diet. kkk. On 5/23/19 at 7:07 PM, a Nursing note documented, New Order Note: Pt having increased nausea and vomiting. PA notified and new orders received to change Zofran to Zofran OTC (over the counter) and start Phenergan Solution (Promethazine HCl) Use 25 mg intravenously every 6 hours as needed for nausea Start Date: 5/23/2019. lll. On 5/24/19 at 2:55 AM, a Nursing note documented, Complained of nausea. Phenergan IV given as ordered. Medication effective. Pt continues on 0.45% normal saline IV at 75 ml/hr. Pt refused all pm medications except zofran. She stated she thought the other medications would cause more nausea or vomiting. Pt continues to have a poor po intake. Currently resting quietly in bed . mmm. On 5/24/19 at 12:18 PM, a Nursing note documented, .new order for Ensure Clear BID per dietary . nnn. On 5/24/19 at 6:38 PM, a Nursing note documented, Pt remains nauseous throughout shift. unable to take anything orally without gagging. Continue on IV fluids. ooo. On 5/25/19 at 2:43 AM, a Nursing note documented, Pt had nausea and vomiting. Phenergan IV given with good effect. Pt continues on 0.45% normal saline IV at 75 ml/hr. Pt refusing all oral medications except zofran. Pt continues to have a poor po intake. [Note: Documented meal intakes from 5/11/19 to 5/26/19 averaged 3.7%] ppp. On 5/26/19 at 2:16 AM, a Nursing note documented, Pt sent to ER (emergency room) on 5/25/19 at 2110 (9:10 PM) for evaluation and treatment per (physician). Patient's husband notified. Report given to ER nurse qqq. On 5/26/19 at 2:27 AM, a Nursing note documented, Patient has been admitted to (a local) Hospital. Dx (diagnosis): GI Bleed. Pt is receiving a blood transfusion tonight. Pt to have a GI consult in the morning. rrr. On 5/26/19 at 2:45 AM, a Nursing note documented, Pt stated she thought she was having a Gall Bladder attack and wanted to go to the ER. Pt stated she was having right lower abdomen pain. Vital signs were within normal limits. Pt insisted she go to the ER. MD notified and an order was given to sent (sic) her to the ER. Pt sent to ER. Resident 32's hospital record was reviewed and revealed the following progress notes: a. On 5/25/19, This is a [AGE] year old female brought to the ER by ambulance from .[facility's name] because of vomiting. The patient tells me she's been vomiting intermittently for several weeks but seems to be getting worse. He (sic) can't hold any fluids down, she is bedridden and generally doesn't feel well. She doesn't feel well. She denies any fever, she has had some diarrhea, hasn't had a normal bowel movement some time. She complains of some mild right-sided abdominal pain. The pain is moderate in intensity .The patient had an episode of emesis which ended up being guaiac positive and does look like coffee grounds .patient is typed and crossed .will transfer 1 unit of packed red cells .(the resident) is given 80 mg pantoprazole and started on pantoprazole drip. Patient received a liter of fluid . b. Resident 32's weight at the hospital was documented to be 221 pounds or 100.9 kilograms. c. On 5/26/19, .(The resident) was hospitalized in January and transition to [facility's name] for ongoing rehabilitation. Patient states that she has not done well over .there and continues to struggle from a functional standpoint. She's had significant abdominal discomfort, nausea, vomiting. She states it's been ongoing for several months. She was brought to the emergency department for evaluation tonight after she's had ongoing nausea, vomiting, poor oral intake and was noted to have coffee-ground emesis concerning for possible upper GI bleed. The patient is extremely weak. She's been lightheaded dizzy. Says she's not really eat (sic) for quite some time Moderate protein-calorie malnutrition .Patient states she has not been eating for quite some time. She has low protein and albumin consistent with moderate protein calorie malnutrition. Hopefully, once renal to evaluate her bleeding and hematologic abnormalities that we will be able to encourage oral intake and improve her malnutrition .my concern his (sic) overall decline over the last several months, she is also lost 20 (sic 200) pounds in the last year and now is no longer ambulatory, has difficulty with feeding and may feed (sic) a feeding tube upon discharge as she can't even tolerate water anymore. d. on 5/27/19, the patient underwent upper endoscopy yesterday .she was found to have erosions in her esophagus, a very tight GE (gastroesophageal) junction, and hemorrhagic gastritis. The patient has not even been able to tolerate water even for the last couple months, she's only hydrating herself with ensure. Family is agreeable to have a small bowel feeding tube in place now, given that she cannot keep up with adequate oral intake. She has lost upwards of 200 pounds in the last year, and a lot of this is likely related to what was found on upper endoscopy. e. On 5/28/19, patient was able to tolerate her small bowel feeding tube yesterday, we slowly titrated up on the tube feeds at 30 cc/h (cubic centimeter per hour) .we're also doing generous water flushes given that she tends to get hyponatremic and has been very dehydrated coming into the hospital. Please see results of the EGS (esophageal gastroscopy) below, but in summary she has significant reasons for not being to tolerate by mouth intake for some time now . On 8/14/19 at 1:32 PM, an interview was conducted with resident 32. Resident 32 stated every time she ate, she would throw up. Resident 32 stated that she then g[TRUNCATED]