**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility failed to clarify diuretic medication prior to administering it for Resident #32. Resident #32 was admitted to the facility on [DATE] with diagnosis that included CHF (congestive heart failure), diabetes and dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/2/24, coded the resident as scoring a 02 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and set up for eating. A review of the comprehensive care plan dated 3/14/24 revealed, FOCUS: Resident has impairment a potential for fluid deficit related to diuretic. INTERVENTIONS: Administer medication as directed by physician. A review of the physician orders dated 3/13/24 revealed Furosemide 20 mg po twice a day. Furosemide 40 mg po twice a day on Friday. A review of the June-September MAR (medication administration record) reveals the unnecessary medication administration on the following dates: Lasix 20 mg po twice a day given on 7/12, AM med pass, Lasix 40 mg po twice a day on Friday given on 7/12 8AM. Lasix 20 mg po twice a day given on 8/16, AM med pass, Lasix 40 mg po twice a day on Friday given on 8/16 8AM. Lasix 20 mg po twice a day given on 8/30, AM med pass, Lasix 40 mg po twice a day on Friday given on 8/30 8AM. Lasix 20 mg po twice a day given on 9/6, AM med pass, Lasix 40 mg po twice a day on Friday given on 9/6 8AM. An interview was conducted on 9/17/24 at 9:00 AM with LPN (licensed practical nurse) #1. When asked about the Lasix order for Resident #32, LPN #1 stated, usually they do not write the order like that. It is usually split up such as Lasix 20 mg po twice a day Saturday through Thursday and Lasix 40 mg po twice a day on Friday. When asked if nursing should have called to clarify the order, LPN #1 stated, yes, they should have called. An interview was conducted on 9/18/24 at 1:00 PM with ASM (administrative staff member) #6, the medical director. When shown the MAR with Lasix 60 mg given, ASM #6 was asked if that was the intended order for Lasix. ASM #6 stated, no, it was meant for Lasix 40 mg po twice a day on Friday and Lasix 20 mg po twice a day the other days of the week. On 9/18/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the facility, the facility's professional standards are based on their policies. The facility's Medication Administration policy reveals, Administer medications within time specified by physician's order, facility policy or manufacturer's information. No further information was provided prior to exit. 6. The facility staff failed to administer medications per physician orders for Resident #48. Resident #48 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ICH (intracranial hemorrhage), hemiplegia, hemiparesis and DM (diabetes mellitus). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/20/24, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and set up for eating. A review of Section O-Special Treatments, Procedures and Programs: K1. Hospice care-coded 'no'. A review of the comprehensive care plan dated 10/31/23 revealed, FOCUS: The resident is at risk for unstable blood glucose related to diabetes. INTERVENTIONS: Administer insulin as directed by the physician. A review of the physician orders dated 3/8/24 revealed Insulin Lispro 100 units/milliliter SQ, administer 3 units with meals, hold if blood sugar less than 120. A review of the physician orders dated 8/5/24 revealed, Amoxicillin-875/125 tablet, give 1 tablet twice a day x 10 days for UTI. A review of the August MAR (medication administration record) revealed, Insulin Lispro 100 units/milliliter not given on 8/27 at 5:00 PM-no insulin syringe. Amoxicillin-875/125 tablet not given on 8/12 at 8:00 AM-drug unavailable, 8/13 at 8:00 AM-drug unavailable and 8/13 8:00 PM-drug unavailable. A review of the September MAR revealed, Insulin Lispro 100 units/milliliter not given 9/2 at 8:00 AM due to no login. An interview was conducted on 9/17/24 at 10:40 AM with LPN (licensed practical nurse) #12. When asked how medications are delivered, LPN #12 stated, there are two runs a day I believe. When asked when medications are delivered, LPN #12 stated, it should be either delivered on the next run or the next day at the latest. I am not sure of the cut off time to get medication orders in for the next run. When asked if there is an emergency drug supply, LPN #12 stated, yes, the Omnicell, we should get the medications from there if they are on the list. When asked if not administering medications as ordered is following the standard of care, LPN #12 stated, no. When asked if the physician should be notified of missed medications, LPN #12 stated, yes. When asked where this would be documented, LPN #12 stated in the progress notes. No progress note documented informing the RP. An interview was conducted on 9/18/24 at 8:50 AM with ASM (administrative staff member) #2, the director of nursing. When asked the process for medication delivery, ASM #2 stated, they deliver twice a day. If they are not delivered, the nurse should check the Omnicell and if it is there, give it. The OTC (over the counter) drugs are located in the top drawer of the medication cart. When asked if medications not administered as ordered is following the standard of care, ASM #2 stated, no, it is not. On 9/18/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the facility, the facility's professional standards are based on their policies. The facility's Medication Administration policy reveals, Administer medications within time specified by physician's order, facility policy or manufacturer's information. No further information was provided prior to exit. 7. The facility staff failed to administer medications as ordered for Resident #16. Resident #16 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: myelodispastic syndrome, seizures and paroxysmal atrial fibrillation. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/31/24, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and set up for eating. A review of the comprehensive care plan dated 6/14/22 revealed, FOCUS: The resident has potential for pain. INTERVENTIONS: Administer pharmacological interventions as ordered by physician and monitor the effectiveness. A review of the physician orders dated 1/10/24 revealed, Acetaminophen 500 mg, give 2 tablets by mouth three times a day for pain. Orders dated 3/7/24: Amiodarone 200 mg give 1 tablet every day for atrial fibrillation. Order 3/21/24: Midodrine 5 mg, give 1 tablet three times a day for hypotension. A review of the physician orders dated 4/15/24 revealed Revlimid capsule 5 mg po, give 1 capsule daily for 21 days. Hold 7 days, repeat. Order 6/1/24: Gabapentin 100 mg give 1 capsule three times a day. Levetiracetam 500 mg po give 1 twice a day. A review of the August MAR (medication administration record) revealed these medications not administered: Gabapentin 100 mg on 8/21 at 2:00 PM, 8:00 PM, 8/22 at 8:00 AM and 8:27 at 2:00 PM. Amiodarone 200 mg on 8/8 at 9:00 AM, 8/14 at 9:00 AM, 8/18 at 9:00 AM and 8/21 at 9:00 AM. Levetiracetam 500 mg on 8/2 at 9:00 PM. A review of the September MAR revealed these medications not administered: Revlimid capsule 5 mg on 9/1 AM med pass, 9/2 AM med pass, 9/11 AM med pass, 9/13 AM med pass and 9/17 AM med pass. Gabapentin 100 mg on 9/1 8:00 PM, 9/2 8:00 AM due to no log in code, 9/12 8:00 PM, 9/13 8:00 AM, 9:13 2:00 PM, 9/13 8:00 PM, 9/14 8:00 AM, 9/14 2:00 PM and 9/14 8:00 PM. Acetaminophen 500 mg on 9/2 at 8:00 AM-no login code. Midrodine 5 mg on 9/2 8:00 AM no login code. An interview was conducted on 9/17/24 at 10:40 AM with LPN (licensed practical nurse) #12. When asked how medications are delivered, LPN #12 stated, there are two runs a day I believe. When asked when medications are delivered, LPN #12 stated, it should be either delivered on the next run or the next day at the latest. I am not sure of the cut off time to get medication orders in for the next run. When asked if there is an emergency drug supply, LPN #12 stated, yes, the Omnicell, we should get the medications from there if they are on the list. When asked if not administering medications as ordered is following the standard of care, LPN #12 stated, no. When shown the current Omnicell Inventory list which revealed the following drugs available on site: Amiodarone 200 mg tablet par 10, Gabapentin 100 mg capsule par 10, Levetiracetam 500 mg tablet par 10, Acetaminophen 500 mg tablet po OTC in top med cart drawer and Midrodine 5 mg tablet par 10; LPN #12 was asked what should have occurred to administer the residents prescribed medications, LPN #12 stated, they should have taken them out of the Omnicell. When asked if the physician should be notified of missed medications, LPN #12 stated, yes. When asked where this would be documented, LPN #12 stated in the progress notes. No progress note documented informing the RP. An interview was conducted on 9/18/24 at 8:50 AM with ASM (administrative staff member) #2, the director of nursing. When asked the process for medication delivery, ASM #2 stated, they deliver twice a day. If they are not delivered, the nurse should check the Omnicell and if it is there, give it. The OTC (over the counter) drugs are located in the top drawer of the medication cart. When asked if medications not administered as ordered is following the standard of care, ASM #2 stated, no, it is not. On 9/18/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the facility, the facility's professional standards are based on their policies. The facility's Medication Administration policy reveals, Administer medications within time specified by physician's order, facility policy or manufacturer's information. No further information was provided prior to exit. 8. The facility staff failed to provide pharmacy services by administering medications as ordered for Resident #88. Resident #88 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: respiratory failure, hypertension, diverticulitis and coronary artery disease. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 10/30/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as max assist for bed mobility, transfer, hygiene and set up for eating. Section O-Special Procedures: coded the resident for antibiotic, midline and isolation. A review of the comprehensive care plan dated 10/27/23 revealed, FOCUS: The resident has infection related to diverticulitis. Resident is on antibiotics for Pneumonia. INTERVENTIONS: Administer antibiotics/antiviral as ordered by the physician. A review of the physician orders dated 10/24/23 revealed Meropenem 1 gram intravenously every 8 hours for diverticulitis for 6 days. A review of the October 2023 MAR (medication administration record) revealed, Meropenem 1 gram IV not administered on 10/25 6:00 AM, 2:00 PM and 10:00 PM; 10/26 6:00 AM, 2:00 PM. An interview was conducted on 9/17/24 at 10:40 AM with LPN (licensed practical nurse) #12. When asked how medications are delivered, LPN #12 stated, there are two runs a day I believe. When asked when medications are delivered, LPN #12 stated, it should be either delivered on the next run or the next day at the latest. I am not sure of the cut off time to get medication orders in for the next run. When asked if there is an emergency drug supply, LPN #12 stated, yes, the Omnicell, we should get the medications from there if they are on the list. When asked if the physician should be notified of missed antibiotics, LPN #12 stated, yes. When asked where this would be documented, LPN #12 stated in the progress notes. No progress note documented informing the RP. An interview was conducted on 9/18/24 at 8:50 AM with ASM (administrative staff member) #2, the director of nursing. When asked the process for medication delivery, ASM #2 stated, they deliver twice a day. If they are not delivered, the nurse should check the Omnicell and if it is there, give it. The OTC (over the counter) drugs are located in the top drawer of the medication cart. On 9/18/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the facility, there is no policy regarding pharmacy delivery. No further information was provided prior to exit. 4. For Resident #63 (R63), the facility staff failed to administer medications as ordered by the physician on multiple dates in August and September of 2024. These medications and supplies were available in the facility in-house medication supply. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/16/24, the resident scored 10 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment documented R63 receiving insulin injections. On 9/15/24 at 6:05 p.m., an interview was conducted with R63 in their room. R63 stated that they had concerns regarding the facility staff running out of their medications and they were missing doses of medications. R63 stated that they had recently gone days without their fentanyl patch because they had to wait for the pharmacy to deliver it and they had missed other medications because the nurses told them they were out. A review of R63's clinical record revealed the following physician's orders: - Fentanyl- Schedule II patch 72hour; 25mcg/hr; amt: 1 patch; transdermal once a day every 3 days. Order Date: 03/06/2024. - Humulin R Regular U-100 Insulin (insulin regular human) [OTC] solution; 100 unit/ml; amt: Per sliding scale; If blood sugar is 201 to 250, give 2 units. If blood sugar is 251 to 300, give 4 units. If blood sugar is 301 to 350, give 6 units. If blood sugar is 351 to 400, give 8 units. If blood sugar is 401 to 450, give 10 units .Before meals and at bedtime. Order Date: 03/06/2024. A review of R63's August 2024 eMAR (electronic medication administration record) failed to evidence the fentanyl patch administered as ordered on 8/24/24 and 8/27/24. The eMAR notes documented the reason for the medication not being administered on 8/24/24 being BLE (bilateral lower extremities) wrapped and 8/27/24 being Drug/item unavailable comment: follow up with pharmacy. A review of the in-house medication inventory documented a par level of five fentanyl 25mcg/hr patches available in house. Further review of the August 2024 eMAR failed to evidence the sliding scale insulin administered as ordered on 8/7/24, 8/20/24 and 8/27/24 at the 11:30 a.m. doses. The eMAR for 8/7/24 and 8/20/24 were observed to be blank and the eMAR notes documented the reason for the medication not being administered on 8/27/24 being Not administered: other comment: no insulin syringe. A review of R63's September 2024 eMAR failed to evidence the fentanyl patch administered as ordered on 9/11/24. The eMAR notes documented the reason for the medication not being administered on 9/11/24 being Drug/item unavailable comment: awaiting from pharmacy, resident and md aware. A review of the in-house medication inventory documented a par level of five fentanyl 25mcg/hr patches available in house. Further review of the September 2024 eMAR failed to evidence the sliding scale insulin administered as ordered on 9/3/24 at 11:30 a.m. The eMAR for 9/3/24 was observed to be blank. On 9/17/24 at 11:08 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that medications were evidenced as given by the nurse signing off on the eMAR and if they were not given it was documented in the progress note why and that the physician was notified. She stated that if the medication was not available from the pharmacy the staff should contact the pharmacy and see if it could be sent over and notify the physician if not available to see if an alternate was appropriate or held. She stated that there was an in-house medication stock that all staff should have access to. She stated that the director of nursing gave access to the agency staff to the in-house medication stock, and some had it and some did not. She stated that they had been working to get everyone access. She stated that if a standing order ran out the pharmacy was called, and they would either send the medication over stat or the staff would pull it from the in-house medication supply. She stated that she was not aware of any insulin syringes running out and they were always available to borrow from their sister facility if needed. She stated that the manager on duty had access to the extra supplies each day. She stated that she remembered R63 running out of the fentanyl patch in the past but was not sure of the details. LPN #1 stated that she could not say why the fentanyl patch was not administered due to the lower extremities being wrapped and thought that it may be a charting error. She stated that it was not a reason to hold the medication. On 9/17/24 at 2:58 p.m., an interview was conducted with OSM (other staff member) #6, central supply. OSM #6 stated that there were medication rooms on each unit that were stocked three times a week with supplies including insulin syringes. She stated that the on-call nurse had a key to the main supply closet and there was always someone to get supplies if anything ran out. She stated that there was a par level of three boxes of insulin syringes kept on each unit and she had not heard of anyone reporting that they ran out of syringes since she had been stocking the supplies. On 9/17/24 at 3:19 p.m., an interview was conducted with RN (registered nurse) #6. RN #6 stated that they had not had any issues with running out of insulin syringes since they had worked at the facility. He stated that there was always someone available to pull supplies from the storage if needed. RN #6 reviewed R63's eMAR notes and stated that there were other areas to place the fentanyl patch and the extremity being wrapped would not be an excuse to not give the medication. He stated that if a medication was not available on the cart the staff were supposed to call the physician and the pharmacy to see if they could get an alternate. He stated that the nurses were able to pull narcotics from the in-house stock supply when the pharmacy gave them a special code that allowed them to take the medication out. On 9/18/24 at 2:59 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern. No further information was provided prior to exit. Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to maintain residents' highest level of well-being for eight of 35 residents in the survey sample, Residents #5, #138, #139, #63, #32, #48, #16, and #88. The findings include: 1. For Resident #5 (R5), the facility staff failed to obtain and verify physician orders for blood sugar checks and insulin (used to treat diabetes) when the resident was re-admitted to the facility on [DATE] at 2:00 p.m. This resulted in harm: on 5/13/24 at approximately 1:15 a.m., R5's blood sugar was documented as 579 (1). The resident was transferred to the hospital, diagnosed with diabetic ketoacidosis (2) and required an insulin drip (insulin that is intravenously infused). R5 was admitted to the facility on [DATE] with a diagnosis of diabetes. A review of R5's clinical record revealed a nurse's note dated 6/5/24 that documented the resident sustained a fall and was transferred to the hospital. R5 was discharged from the hospital back to the facility on 5/11/24. The hospital discharge medication list dated 5/11/24 documented, CONTINUE taking these medications: -Insulin Lispro 100 unit/mL (milliliter) insulin pen- two units beneath the skin Three Times Daily with Meals. If eats at least 50% of meal or drinks a supplement shake. -Insulin Lispro 100 unit/mL insulin pen- Inject 0-3 Units beneath the skin 4 Times a Day Before Meals & at Bedtime. Per sliding scale (based on the resident's blood sugars): 250-350=1 unit 351-400=2 units 401-800=3 units Call & notify MD (Medical Doctor) if BG (Blood Glucose) > (greater than) 400. -LEVEMIR 100 unit/mL (3 mL) insulin pen- Inject 9 Units beneath the skin Every Night at Bedtime. Further review of R5's clinical record failed to reveal any physician's medication orders when the resident was re-admitted on [DATE]. A review of R5's MAR (medication administration record) for 5/11/24 and 5/12/24 failed to reveal any medication orders. A nurse's note dated 5/11/24 at 4:13 p.m. documented, Pt (Patient) returned from (name of hospital) at 1400 (2:00 p.m.) via stretcher. Received report from hospital. Pt is alert and oriented. Generalized bruising visible on face, scalp and both legs. Dried blood on face and scalp. Left side of hair line has 2 sutures. Bridge of nose with 3 sutures intact. Rt (Right) knee with honeycomb dressing bilaterally. Abrasion lower rt leg front. Left hip with Honeycomb dressing dry and intact. Petal pulse present bilaterally. Left side weaker than right, chronic issue. Lungs clear, abd (abdomen) soft with bowel sounds all 4 quads (quadrants). Pt has script for Neurontin q (every) 8 hours prn (as needed) for pain. BS (Blood sugar) 132. Vitals 139/63 (blood pressure), 92 (pulse), 16 (respirations), 98 (temperature), 96% (oxygen level). A nurse's note dated 5/12/24 at midnight (5/11/24 into 5/12/24) documented, During hand off report, previous nurse reports to this nurse that patient arrived to facility at 1400 but she did not confirm orders with MD (Medical Doctor)/enter orders in MAR (medication administration record). Writer contacted (name of physician group) on call to confirm orders. Writer spoke with (name of a nurse practitioner). (Name of the nurse practitioner) refuses to confirm orders with nurse because patient came to facility at 1400. Writer attempted to explain to On call (name of nurse practitioner) that this nurse shift started at 1900 (7:00 p.m.) and this nurse just finished passing medication on unit and just needed to confirm the orders because previous nurse did not. (Name of nurse practitioner) states, 'I am not doing that. I am not approving medications after 8pm.' Due to (name of physician group) (name of nurse practitioner) refusing to confirm orders for patient, writer cannot enter patients [sic] orders/treatments into MAR at this time. Will endorse oncoming nurse. Will make management aware of clinical situation. There were no nurses' notes documented in R5's clinical record during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24. A nurse's note dated 5/12/24 at 10:58 p.m. (recorded as a late entry on 5/13/24), documented, Received care of resident at 22:40 (10:40 p.m.) Resident had been released from the hospital a day before after falling face first on concrete. Resident states she is in a severe pain. This nurse looked at resident's MAR which was inadequately updated since resident has been back. It was noted that the last time resident received insulin or glucose checks was on 05/08/2024. This nurse noted that the only pain medicine ordered is Tylenol 1000mg (milligrams). This nurse called nurse on 3West in (name of hospital) to get more information about resident's stay in the hospital. The only discharge papers were a list of medications. No Dx (diagnoses), tests, test results were noted. Nurse at (name of hospital) was not able to give any information since the resident had already been released. On call doctor was noted; on call doctor advised nurse to either administer Tylenol or send resident to the hospital if pain gets too intense. Resident's brother was noted and he drove to be at his sister's bedside at 0030 (12:30 a.m.). Tylenol was not effective. Resident was repositioned; ineffective. Blood glucose 579. Lispro and Levemir administered. 911 was called per brother's request. Resident was transferred to (name of hospital) at 0115 (1:15 a.m.) via stretcher. Resident has been admitted to the hospital unit. A hospital Discharge summary dated [DATE] documented, Per patient, since discharge (from the hospital on 5/11/24) was not able to get her insulin and noted increased pain on bilateral lower ext (extremities) .EMS reported BS (Blood Sugar) 600. The discharge summary further documented a diagnosis of diabetic ketoacidosis, and the resident was administered an insulin drip at the hospital. A facility synopsis of events dated 5/22/24 documented, (R5's) brother, (name), called the DON (Director of Nursing) to inquire about prescribed medications and administration. Based upon this concern, the facility immediately started an internal investigation. The facility interviewed all nurses responsible for (R5's) care, the physician on-call upon the resident's return to the community and reviewed the resident's medical record. (R5) returned to the facility on 5/11/24 after an unrelated hospitalization. A review of the physician orders revealed medication errors regarding transcription of new orders upon return to the facility. Interviews of the nursing team members responsible for (R5's) care revealed unsuccessful attempts to verify the medications with the resident provider group via telephone upon return. Upon the orders being unsuccessfully verified (R5) to return to the ER (Emergency Room) for evaluation. The resident returned to the facility on 5/17/24 .Based on the schedule, the nurses that would have completed her admission and or delivered medications. The nurses who assumed care for the resident were placed on a do not return list and are not allowed to work in the facility . The synopsis contained multiple statements by facility staff as documented below. A statement signed on 5/15/24 by RN (registered nurse) #3 (the nurse who worked the 7:00 a.m. to 7:00 p.m. shift on 5/12/24 on another unit) documented, On Sunday 5/12/24 on Day shift provider for (R5) called unit one inquiring about resident if she had returned from hospital. Updated provider that resident returned but did not have any pain medication. Provider reporting that they would escribe (electronically prescribe) pain medication to (name of pharmacy), did not specify what medication, dose, or frequency. RN #3 was available for interview during the survey. A statement signed by LPN (licensed practical nurse) #7 (the nurse who worked the 7:00 p.m. to 7:00 a.m. shift on another unit 5/12/24 into 5/13/24) (no signature date) documented, To Whom it may concern: I, (name of LPN #7) was approached by (LPN #6), regarding patient, (R5) on Unit 1 nurses station. (LPN #6) stated, '(R5) is having uncontrolled pain and she has no pain medications.' (LPN #6) continued, 'Oh! and her blood sugar is around 600.' This nurse then replied, 'Send her out.' (LPN #6) then replied, 'Well I gave her Levemir for her sugar.' I again stated, 'Send her out.' (LPN #6) walked to her computer to print off (R5's) paperwork for transfer. (R5's) brother was in her room. When (LPN #6) stated, 'She has only 1 or 2 medications, so I didn't print it off.' This nurse then went to computer and there were no medications under (R5's) orders. This nurse stated to EMTs (Emergency Medical Technicians) that patient 'does not have any medications on her orders.' This nurse stated, 'I don't know of any medications being administered, other than Levemir (LPN #6) gave her.' This nurse then left the room and the unit. Another statement signed by LPN #7 (no signature date) documented, To Whom it may concern: I, (name of LPN #7), had no interaction with nurse on unit 2, until 1020 PM on May 12th 2024. Said nurse on unit 2 (RN #2) approached the nurses station on unit 1 @ 1020 PM regarding her relief. On call nurse (LPN #8) was notified and there was no other interaction after 1030 PM.- Regarding (RN #2) (the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24). LPN #7 was not available for interview during the survey. A statement signed by LPN #8 (R5's unit manager) on 5/13/24 documented, On Monday 5/13/24, I came in to relieve the nurse (LPN #6) because she needed to leave by 630 am. (LPN #6) gave me report on the unit, she told me that she sent (R5) out because of the pain she was having. I asked her did she let anyone know. She stated no it was late it was 1 am. I then stated two residents went to the hospital on your watch, on call should have been called. I explained that and proceeded to take report. A statement signed by LPN #8 on 5/15/24 documented, On 5/12/24 at 12:32 am, nurse (LPN #5) text my phone to state the nurse during the day did not get the meds approved at 2 pm when the resident was admitted on 5.11.24. (LPN #5) stated she called (name of physician group) on call to get the meds verified but the on call (name of nurse practitioner) refused to verify the meds because she stated she doesn't verify meds after 8pm. Once I woke up to the text at 0738 (7:38 a.m.) I contacted (LPN #5) and she explained what she wrote in her text. I then called (name of medical director) explaining what happened, he stated this was not the first time on call has done this that he would be reaching out. Resident meds still needed to be verified, (name of medical director) stated to call on call and have them verify the meds. (Name of medical director) was contacted by me on 5/12/24 at 0838 (8:38 a.m.). This writer then called the building x (times) 4, no one answered. I then called the housekeeper supervisor to check all phones in the building because no one was picking up, she took phone to nurse. I told (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24) to place the orders in (name of computer system) because she stated to me that (RN #3), the nurse on unit one already verified the meds. (RN #2) stated she had one more resident to give meds to and she was going to put the orders in. LPN #8 was not available for interview during the survey. On 9/17/24 at 2:10 p.m., a telephone interview was conducted with LPN #5. LPN #5[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement an effective pain management program for two of 35 residents in the survey sample, Residents #5 and #138. The findings include: 1. For Resident #5 (R5), the facility staff failed to obtain and verify physician orders for pain medications when the resident was re-admitted to the facility at 2:00 p.m. on 5/11/24 with two broken femurs (thigh bones). This resulted in harm: on 5/13/24 at approximately 1:15 a.m., R5 was transferred to the hospital for inadequate pain control. A review of R5's clinical record revealed a nurse's note dated 6/5/24 that documented the resident sustained a fall and was transferred to the hospital. R5 was discharged from the hospital back to the facility on 5/11/24. The hospital Discharge summary dated [DATE] documented a primary discharge diagnosis of bilateral distal femur fractures secondary to osteoporosis and a mechanical fall. The hospital discharge medication list documented, CONTINUE taking these medications: gabapentin (used to treat seizures and pain) 400 mg (milligrams)- one capsule every eight hours for five days. Further review of R5's clinical record failed to reveal any physician's medication orders when the resident was re-admitted on [DATE]. A review of R5's MAR (medication administration record) for 5/11/24 and 5/12/24 failed to reveal any medication orders. A nurse's note dated 5/11/24 at 4:13 p.m. documented, Pt (Patient) returned from (name of hospital) at 1400 (2:00 p.m.) via stretcher. Received report from hospital. Pt is alert and oriented. Generalized bruising visible on face, scalp and both legs. Dried blood on face and scalp. Left side of hair line has 2 sutures. Bridge of nose with 3 sutures intact. Rt (Right) knee with honeycomb dressing bilaterally. Abrasion lower rt leg front. Left hip with Honeycomb dressing dry and intact. Petal pulse present bilaterally. Left side weaker than right, chronic issue. Lungs clear, abd (abdomen) soft with bowel sounds all 4 quads (quadrants). Pt has script for Neurontin (gabapentin) q (every) 8 hours prn (as needed) for pain. BS (Blood sugar) 132. Vitals 139/63 (blood pressure), 92 (pulse), 16 (respirations), 98 (temperature), 96% (oxygen level). A nurse's note dated 5/12/24 at midnight (5/11/24 into 5/12/24) documented, During hand off report, previous nurse reports to this nurse that patient arrived to facility at 1400 but she did not confirm orders with MD (Medical Doctor)/enter orders in MAR (medication administration record). Writer contacted (name of physician group) on call to confirm orders. Writer spoke with (name of a nurse practitioner). (Name of the nurse practitioner) refuses to confirm orders with nurse because patient came to facility at 1400. Writer attempted to explain to On call (name of nurse practitioner) that this nurse shift started at 1900 (7:00 p.m.) and this nurse just finished passing medication on unit and just needed to confirm the orders because previous nurse did not. (Name of nurse practitioner) states, 'I am not doing that. I am not approving medications after 8pm.' Due to (name of physician group) (name of nurse practitioner) refusing to confirm orders for patient, writer cannot enter patients [sic] orders/treatments into MAR at this time. Will endorse oncoming nurse. Will make management aware of clinical situation. An admission/readmission observation dated 5/12/24 at 2:59 a.m. documented R5 reported pain or hurting almost constantly over the last five days, the pain almost constantly made it hard to sleep, the pain almost constantly limited day-to-day activities, the pain was rated as an eight on a scale from zero to ten, and the intensity of the pain was severe. There were no nurses' notes documented in R5's clinical record during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24. R5's May 2024 MAR documented the resident's pain as a ten (on a scale from zero to ten) during the day shift on 5/12/24 and the resident's pain as an eight during the night shift on 5/12/24. A nurse's note dated 5/12/24 at 10:58 p.m. (recorded as a late entry on 5/13/24), documented, Received care of resident at 22:40 (10:40 p.m.) Resident had been released from the hospital a day before after falling face first on concrete. Resident states she is in a severe pain. This nurse looked at resident's MAR which was inadequately updated since resident has been back .This nurse noted that the only pain medicine ordered is Tylenol 1000mg (milligrams). This nurse called nurse on 3West in (name of hospital) to get more information about resident's stay in the hospital. The only discharge papers were a list of medications. No Dx (diagnoses), tests, test results were noted. Nurse at (name of hospital) was not able to give any information since the resident had already been released. On call doctor was noted; on call doctor advised nurse to either administer Tylenol or send resident to the hospital if pain gets too intense. Resident's brother was noted and he drove to be at his sister's bedside at 0030 (12:30 a.m.). Tylenol was not effective. Resident was repositioned; ineffective .911 was called per brother's request. Resident was transferred to (name of hospital) at 0115 (1:15 a.m.) via stretcher. Resident has been admitted to the hospital unit. A hospital Discharge summary dated [DATE] documented, Per patient, since discharge (from the hospital on 5/11/24) was not able to get her insulin and noted increased pain on bilateral lower ext (extremities) .Started insulin drip per DKA (diabetic ketoacidosis) protocol and pain meds and admitted . A facility synopsis of events dated 5/22/24 documented, (R5's) brother, (name), called the DON (Director of Nursing) to inquire about prescribed medications and administration. Based upon this concern, the facility immediately started an internal investigation. The facility interviewed all nurses responsible for (R5's) care, the physician on-call upon the resident's return to the community and reviewed the resident's medical record. (R5) returned to the facility on 5/11/24 after an unrelated hospitalization. A review of the physician orders revealed medication errors regarding transcription of new orders upon return to the facility. Interviews of the nursing team members responsible for (R5's) care revealed unsuccessful attempts to verify the medications with the resident provider group via telephone upon return. Upon the orders being unsuccessfully verified (R5) to return to the ER (Emergency Room) for evaluation. The resident returned to the facility on 5/17/24 .Based on the schedule, the nurses that would have completed her admission and or delivered medications. The nurses who assumed care for the resident were placed on a do not return list and are not allowed to work in the facility . The synopsis contained multiple statements by facility staff as documented below. A statement signed on 5/15/24 by RN (registered nurse) #3 (the nurse who worked the 7:00 a.m. to 7:00 p.m. shift on 5/12/24 on another unit) documented, On Sunday 5/12/24 on Day shift provider for (R5) called unit one inquiring about resident if she had returned from hospital. Updated provider that resident returned but did not have any pain medication. Provider reporting that they would escribe (electronically prescribe) pain medication to (name of pharmacy), did not specify what medication, dose, or frequency. RN #3 was available for interview during the survey. A statement signed by LPN (licensed practical nurse) #7 (the nurse who worked the 7:00 p.m. to 7:00 a.m. shift on another unit 5/12/24 into 5/13/24) (no signature date) documented, To Whom it may concern: I, (name of LPN #7) was approached by (LPN #6), regarding patient, (R5) on Unit 1 nurses station. (LPN #6) stated, '(R5) is having uncontrolled pain and she has no pain medications.' (LPN #6) continued, 'Oh! and her blood sugar is around 600.' This nurse then replied, 'Send her out.' (LPN #6) then replied, 'Well I gave her Levemir for her sugar.' I again stated, 'Send her out.' (LPN #6) walked to her computer to print off (R5's) paperwork for transfer. (R5's) brother was in her room. When (LPN #6) stated, 'She has only 1 or 2 medications, so I didn't print it off.' This nurse then went to computer and there were no medications under (R5's) orders. This nurse stated to EMTs (Emergency Medical Technicians) that patient 'does not have any medications on her orders.' This nurse stated, 'I don't know of any medications being administered, other than Levemir (LPN #6) gave her.' This nurse then left the room and the unit. Another statement signed by LPN #7 (no signature date) documented, To Whom it may concern: I, (name of LPN #7), had no interaction with nurse on unit 2, until 1020 PM on May 12th 2024. Said nurse on unit 2 (RN #2) approached the nurses station on unit 1 @ 1020 PM regarding her relief. On call nurse (LPN #8) was notified and there was no other interaction after 1030 PM.- Regarding (RN #2) (the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24). LPN #7 was not available for interview during the survey. A statement signed by LPN #8 (R5's unit manager) on 5/13/24 documented, On Monday 5/13/24, I came in to relieve the nurse (LPN #6) because she needed to leave by 630 am. (LPN #6) gave me report on the unit, she told me that she sent (R5) out because of the pain she was having. I asked her did she let anyone know. She stated no it was late it was 1 am. I then stated two residents went to the hospital on your watch, on call should have been called. I explained that and proceeded to take report. A statement signed by LPN #8 on 5/15/24 documented, On 5/12/24 at 12:32 am, nurse (LPN #5) text my phone to state the nurse during the day did not get the meds approved at 2 pm when the resident was admitted on 5.11.24. (LPN #5) stated she called (name of physician group) on call to get the meds verified but the on call (name of nurse practitioner) refused to verify the meds because she stated she doesn't verify meds after 8pm. Once I woke up to the text at 0738 (7:38 a.m.) I contacted (LPN #5) and she explained what she wrote in her text. I then called (name of medical director) explaining what happened, he stated this was not the first time on call has done this that he would be reaching out. Resident meds still needed to be verified, (name of medical director) stated to call on call and have them verify the meds. (Name of medical director) was contacted by me on 5/12/24 at 0838 (8:38 a.m.). This writer then called the building x (times) 4, no one answered. I then called the housekeeper supervisor to check all phones in the building because no one was picking up, she took phone to nurse. I told (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24) to place the orders in (name of computer system) because she stated to me that (RN #3), the nurse on unit one already verified the meds. (RN #2) stated she had one more resident to give meds to and she was going to put the orders in. LPN #8 was not available for interview during the survey. On 9/17/24 at 2:10 p.m., a telephone interview was conducted with LPN #5. LPN #5 stated she could not recall details and to refer to her note. RN #2 was not available for interview during the survey. A printed text message from LPN #6 (the nurse who sent R5 to the hospital on the night of 5/12/24) to ASM (administrative staff member) #2 (the Director of Nursing) (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8) and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). Another printed text message from LPN #6 to ASM #2 (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8) and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). ASM #2, I have been waiting for a phone call from you. Since I haven't, I am going to write an incident report to my agency and I will report you to the VA (Virginia) board of nursing. The patient I sent to the hospital hadn't got her insulin for a day and a half because the dr (doctor) on call refused to verify the meds since (R5) didn't return to the facility while she was on call . LPN #6 was not available for interview during the survey. A statement signed by ASM #2 (the Director of Nursing) (no date) documented, On 5/13/2024, 11 a.m. I called (name of nursing staff agency) to request (RN #1's) telephone number and reported Nurse's failure to initiate an admission nor verify medications to treat resident. Resident arrived at 2pm. Staffing agency, stated that they would contact Nurse and have her return my call. Upon return call, I inquired of the reason (RN #1- the nurse who cared for R5 when the resident was re-admitted on [DATE]) did not initiate the admission process for the readmission. Nurse verbalized, she was extremely busy. 'I had to discharge a resident and was not sure of the process, and that the Unit Manager (who was on call and in the building) assisted her with printing discharge paperwork. 'I am not familiar with your version of (name of computer software), I use (name of computer software) at another facility, and however I am more familiar with (name of another computer software). I did ask (LPN #7) on the other unit, what I needed to do for the admission, and she told me the resident was a regular resident and all the medications for her were on the cart.' I went on to ask the Nurse had she received a discharge packet from the Medical transportation personnel, her response was, 'yes.' I continued by referencing her admission note and resident's script upon her return and inquired about the failure to call MD (medical doctor) for verification of orders. Nurse (RN #1) stated, she was unaware of the need to call since, she was told her medications were on the cart. I followed up by asking, Did you see a MAR (medication administration record) for the resident? 'No.' Did you ask the Unit Manager for assistance? 'No.' When you completed your assessment [sic] the resident and noted the script for Gabapentin (used to treat seizures and pain), why did you not input the new script? 'I continued to pass the other medications to the other residents.' Have you ever performed an admission? 'Yes, your system is different, and in (name of another computer system) after putting the resident in the system the admission assessments automatically populates [sic].' 'I informed the oncoming nurse that I had an admission but did not finish it and she said she would finish it, I offered to stay if she would walk me through the process, but she told me she would complete it.' Interviewed (LPN #5- the nurse who cared for R5 during the 7:00 p.m. to 7:00 a.m. shift 5/11/24 into 5/12/24), via telephone. She verbalized she did inform the nurse that she would complete the admission, but initially was not aware of that the medications were not transcribed nor verified. (LPN #5), during her medication pass noted (R5) did not have a MAR, immediately after her medication pass, she made an attempt to call to verify orders, and after speaking with the On call Physician, who would not verify the orders. She texted the On Call Nurse. (LPN #5) was asked, why she did not call (name of the medical director) and she verbalized that she was not aware that she could since there was an On Call system in place. I educated (LPN #5), to call instead of text the On Call Nurse management team member or myself, and in cases of this importance (name of the medical director) can be called. (LPN #5) added that she did inform the oncoming Nurse to call to have the orders verified. However, the oncoming Nurse stated, 'I will not be doing that because it [sic] Mother's Day.' Called (name of nurse staffing agency), informed that of (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24), failure to complete Medication Administration Record documentation, failure to follow up on a readmission, and failure to complete skilled documentation. Interviewed via telephone, (RN #2), stated she 'thought' she signed off her medications, 'I was constantly on the cart, tending to residents, answering questions for family members, and made attempts to control (R5's) pain since the resident only came back with gabapentin. They called in Tramadol (used to treat pain) to the pharmacy and it did not come in, then I got an order for Tylenol 1000 mg (milligrams) and gave it to resident.' I inquired of why the orders were not transcribed on the MAR nor documented in the system and was she aware that (R5's) medication were not verified? 'There was a lot going on and I planned to do it.' Why did you did [sic] not call the On call Nurse for assistance? 'I do not have anyone's number and like I said it was a lot going on.' (RN #2) was informed that there is a calendar at the desk with all On Call Nurses numbers attached. (RN #2) said she did not have time to look for anyone's numbers, but she did ask (LPN #7) for assistance. On 9/17/24 at 9:33 a.m., an interview was conducted with LPN #4 (the current unit manager). LPN #4 stated that when a resident is re-admitted from the hospital, he or she returns with a package that contains a medication list and discharge instructions, and the admitting nurse should call the doctor to verify the medication list. LPN #4 stated sometimes the doctor changes medication orders and after medications have been verified, the nurse should put all orders into the computer system. LPN #4 stated that after orders are put into the computer system, they are transmitted to the pharmacy and transcribed onto a MAR. LPN #4 stated she would not stop in the middle of a medication pass to complete this process, but it should be done as soon as the resident arrives. LPN #4 stated, That's the first thing they should do because we need the meds. LPN #4 stated if the physician or nurse practitioner will not verify medications upon re-admission, the admitting nurse should call the medical director and inform the Director of Nursing. On 9/17/24 at 10:46 a.m., an interview was conducted with ASM #2 (the Director of Nursing). ASM #2 stated that when a resident is re-admitted , the nurse should greet the resident, make sure the resident is comfortable, then go to the desk and open the packet of information and orders from the hospital. ASM #2 stated the nurse should enter/transcribe the orders into the queue in the computer system then verify the orders with the physician because the physician may want to change the orders. ASM #2 stated that after the orders are verified with the physician, the nurse should make the orders active in the computer system so the orders are activated onto the MAR and sent to the pharmacy. ASM #2 stated she was not made aware of the above incident regarding R5 until the resident was being sent back to the hospital on [DATE] into 5/13/24). ASM #2 stated it was the middle of the night and she received a phone call from R5's brother. ASM #2 stated the facility staff could not manage R5's pain. ASM #2 stated R5's brother said R5 was in significant pain and had not received any pain medications in over 24 hours. ASM #2 stated that at that point, all she could do was agree that pain medications should have been obtained for R5 then she called the facility staff to make sure they sent R5 to the hospital and documented a note. ASM #5 stated that when R5 was re-admitted to the facility on [DATE], the first nurse should have queued the medications in the computer system, called the physician to verify the medications, sent the medication orders to the pharmacy, and if the resident was in pain, the nurse should have contacted the pharmacy and obtained medications from the box in the facility. ASM #2 stated that if the nurse didn't know what to do, she should have called the on-call nurse or ASM #2. ASM #2 stated that if the nurse practitioner refused to verify the medications, then the nurse should have notified her so she could have notified the medical director. On 9/17/24 at 11:23 a.m., an interview was conducted with ASM #6 (the medical director). ASM #6 stated the responsibilities of the on-call physician or nurse practitioner are to take care of the patient, verify orders, and send the pharmacy an e-script (electronic prescription) if needed. In regard to the above incident involving R5, ASM #6 stated that if he recalled, there were errors on multiple sides. ASM #6 stated the orders should have been called in to the on-call nurse practitioner as soon as R5 arrived to the facility but it was the responsibility of the on-call nurse practitioner to verify orders and send e-scripts whenever called, regardless of the time. ASM #6 stated, It is our responsibility to make sure it happens with as little delay as possible. ASM #6 stated he should have been notified when the on-call nurse practitioner refused to verify R5's orders but he was not notified until the next day. ASM #6 stated the on-call nurse practitioner does not round at the facility and is only on-call for the group, but he escalated the incident to the chief medical officer because the patient actually came to some harm and had to go the emergency room for a lack of order verification and pain management. On 9/18/24 at 1:11 p.m. another interview was conducted with ASM #6. ASM #6 was made aware of the statement signed by LPN #8 on 5/13/24 that documented he (ASM #6) was notified on 5/12/24 at 8:38 a.m. ASM #6 stated he went back through his phone records. ASM #6 stated that during the morning on 5/12/24, LPN #8 made him aware that R5 was admitted at 2:00 p.m. on the previous day and the medications were not called to the on-call nurse practitioner until midnight and the nurse practitioner declined to verify the medications because she thought they should have been called to her earlier in the day. ASM #6 stated he told LPN #8 to call the on-call nurse practitioner back since it was not after 8:00 p.m., and if the nurse practitioner did not verify the medications, call him back. ASM #6 stated he was not notified again until R5 was sent to the hospital. On 9/17/24 at 1:25 p.m., ASM (administrative staff member) #1 (the interim administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Pain Management Protocol documented, It is the policy of this community to ensure any resident that is admitted to the facility is assessed for pain and/or the potential for pain in order for the resident to reach and maintain his/her highest practicable level of physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. For Resident #138 (R138), the facility staff failed to administer physician prescribed pain medications. The Brief Interview for Mental Status (BIMS) form dated, 9/12/24, the resident scored a 12 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. R138 was admitted to the facility on [DATE] at 6:21 p.m. An interview was conducted with R138 on 9/15/24 at 5:06 p.m. R138 stated he had pain upon admission, and they didn't give him his pain medications. It took a while to get his pain under control because he stated he got behind the curve with it. The physician orders dated 9/10/24, documented, Morphine tablet extended release; 15 mg (milligrams); 3 tabs (tablets) every 12 hours for malignant neoplasm of prostate. The September 2024 MAR (medication administration record) documented the above order. There were blanks on the MAR for 9/10/24 at 9:00 p.m., 9/11/24 at 9:00 p.m. and 9/12/24 at 9:00 p.m. The Controlled Medication Utilization Record documented the medication was received at the facility on 9/12/24. Review of the Omnicell (on site emergency medication system) inventory list failed to evidence the Morphine extended release was stocked in it. The Baseline Care plan dated 9/10/24, documented in part, Approach: Pain - evaluation of pain will be performed routinely to address pain management needs. I will receive pain medication per physician/NP (nurse practitioner) orders. Paim medication effectiveness will be documented and recorded as needed. An interview was conducted with LPN (licensed practical nurse) #12 on 9/17/24 at 10:32 a.m. When asked how you get narcotics for a new admission, LPN #12 stated if they don't have the medications here, there's the Omnicell. You need two nurses to get out narcotics and the pharmacy must give you a code to get into it. LPN #12 stated, when she gets report from the hospital, she asks them to medicate the resident for pain, if indicated, as transfers can be rough on the resident. LPN #12 further stated if you don't tell the pharmacy, you want them on the first run, then you don't get them until the night run. When asked about R138, LPN #12 stated she had done his admission, the narcotics should have come that night, unless there was an insurance delay. She stated someone had added (R138) to the system but can't transmit the orders to the pharmacy until the resident is actually in the building. ASM (administrative staff member) #1, the interim administrator and ASM #2, the director of nursing, were made aware of the above findings on 9/17/24 at 5:13 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide physician services for one of 35 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the on-call nurse practitioner failed to verify medication orders when the resident was re-admitted on [DATE]. This resulted in harm: on 5/13/24 at approximately 1:15 a.m., R5 was transferred to the hospital for inadequate pain control. Also, the R5's blood sugar was documented as 579 (1), the resident was diagnosed with diabetic ketoacidosis (2), and the resident required an insulin drip (insulin that is intravenously infused). A review of R5's clinical record revealed a nurse's note dated 6/5/24 that documented the resident sustained a fall and was transferred to the hospital. R5 was discharged from the hospital back to the facility on 5/11/24. The hospital Discharge summary dated [DATE] documented a primary discharge diagnosis of bilateral distal femur fractures secondary to osteoporosis and a mechanical fall. The hospital discharge medication list documented, CONTINUE taking these medications: -gabapentin (used to treat seizures and pain) 400 mg (milligrams)- one capsule every eight hours for five days. -Insulin Lispro 100 unit/mL (milliliter) insulin pen- two units beneath the skin Three Times Daily with Meals. If eats at least 50% of meal or drinks a supplement shake. -Insulin Lispro 100 unit/mL insulin pen- Inject 0-3 Units beneath the skin 4 Times a Day Before Meals & at Bedtime. Per sliding scale (based on the resident's blood sugars): 250-350=1 unit 351-400=2 units 401-800=3 units Call & notify MD (Medical Doctor) if BG (Blood Glucose) > (greater than) 400. -LEVEMIR 100 unit/mL (3 mL) insulin pen- Inject 9 Units beneath the skin Every Night at Bedtime. Further review of R5's clinical record failed to reveal any physician's medication orders when the resident was re-admitted on [DATE]. A review of R5's MAR (medication administration record) for 5/11/24 and 5/12/24 failed to reveal any medication orders. A nurse's note dated 5/11/24 at 4:13 p.m. documented, Pt (Patient) returned from (name of hospital) at 1400 (2:00 p.m.) via stretcher. Received report from hospital. Pt is alert and oriented. Generalized bruising visible on face, scalp and both legs. Dried blood on face and scalp. Left side of hair line has 2 sutures. Bridge of nose with 3 sutures intact. Rt (Right) knee with honeycomb dressing bilaterally. Abrasion lower rt leg front. Left hip with Honeycomb dressing dry and intact. Petal pulse present bilaterally. Left side weaker than right, chronic issue. Lungs clear, abd (abdomen) soft with bowel sounds all 4 quads (quadrants). Pt has script for Neurontin q (every) 8 hours prn (as needed) for pain. BS (Blood sugar) 132. Vitals 139/63 (blood pressure), 92 (pulse), 16 (respirations), 98 (temperature), 96% (oxygen level). A nurse's note dated 5/12/24 at midnight (5/11/24 into 5/12/24) documented, During hand off report, previous nurse reports to this nurse that patient arrived to facility at 1400 but she did not confirm orders with MD (Medical Doctor)/enter orders in MAR (medication administration record). Writer contacted (name of physician group) on call to confirm orders. Writer spoke with (name of a nurse practitioner). (Name of the nurse practitioner) refuses to confirm orders with nurse because patient came to facility at 1400. Writer attempted to explain to On call (name of nurse practitioner) that this nurse shift started at 1900 (7:00 p.m.) and this nurse just finished passing medication on unit and just needed to confirm the orders because previous nurse did not. (Name of nurse practitioner) states, 'I am not doing that. I am not approving medications after 8pm.' Due to (name of physician group) (name of nurse practitioner) refusing to confirm orders for patient, writer cannot enter patients [sic] orders/treatments into MAR at this time. Will endorse oncoming nurse. Will make management aware of clinical situation. There were no nurses' notes documented in R5's clinical record during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24. A nurse's note dated 5/12/24 at 10:58 p.m. (recorded as a late entry on 5/13/24), documented, Received care of resident at 22:40 (10:40 p.m.) Resident had been released from the hospital a day before after falling face first on concrete. Resident states she is in a severe pain. This nurse looked at resident's MAR which was inadequately updated since resident has been back. It was noted that the last time resident received insulin or glucose checks was on 05/08/2024. This nurse noted that the only pain medicine ordered is Tylenol 1000mg (milligrams). This nurse called nurse on 3West in (name of hospital) to get more information about resident's stay in the hospital. The only discharge papers were a list of medications. No Dx (diagnoses), tests, test results were noted. Nurse at (name of hospital) was not able to give any information since the resident had already been released. On call doctor was noted; on call doctor advised nurse to either administer Tylenol or send resident to the hospital if pain gets too intense. Resident's brother was noted and he drove to be at his sister's bedside at 0030 (12:30 a.m.). Tylenol was not effective. Resident was repositioned; ineffective. Blood glucose 579. Lispro and Levemir administered. 911 was called per brother's request. Resident was transferred to (name of hospital) at 0115 (1:15 a.m.) via stretcher. Resident has been admitted to the hospital unit. A hospital Discharge summary dated [DATE] documented, Per patient, since discharge (from the hospital on 5/11/24) was not able to get her insulin and noted increased pain on bilateral lower ext (extremities) .EMS reported BS (Blood Sugar) 600. Started insulin drip per DKA (diabetic ketoacidosis) protocol and pain meds and admitted . A facility synopsis of events dated 5/22/24 documented, (R5's) brother, (name), called the DON (Director of Nursing) to inquire about prescribed medications and administration. Based upon this concern, the facility immediately started an internal investigation. The facility interviewed all nurses responsible for (R5's) care, the physician on-call upon the resident's return to the community and reviewed the resident's medical record. (R5) returned to the facility on 5/11/24 after an unrelated hospitalization. A review of the physician orders revealed medication errors regarding transcription of new orders upon return to the facility. Interviews of the nursing team members responsible for (R5's) care revealed unsuccessful attempts to verify the medications with the resident provider group via telephone upon return. Upon the orders being unsuccessfully verified (R5) to return to the ER (Emergency Room) for evaluation. The resident returned to the facility on 5/17/24 .Based on the schedule, the nurses that would have completed her admission and or delivered medications. The nurses who assumed care for the resident were placed on a do not return list and are not allowed to work in the facility . The synopsis contained multiple statements by facility staff as documented below. A statement signed on 5/15/24 by RN (registered nurse) #3 (the nurse who worked the 7:00 a.m. to 7:00 p.m. shift on 5/12/24 on another unit) documented, On Sunday 5/12/24 on Day shift provider for (R5) called unit one inquiring about resident if she had returned from hospital. Updated provider that resident returned but did not have any pain medication. Provider reporting that they would escribe (electronically prescribe) pain medication to (name of pharmacy), did not specify what medication, dose, or frequency. RN #3 was available for interview during the survey. A statement signed by LPN (licensed practical nurse) #7 (the nurse who worked the 7:00 p.m. to 7:00 a.m. shift on another unit 5/12/24 into 5/13/24) (no signature date) documented, To Whom it may concern: I, (name of LPN #7) was approached by (LPN #6), regarding patient, (R5) on Unit 1 nurses station. (LPN #6) stated, '(R5) is having uncontrolled pain and she has no pain medications.' (LPN #6) continued, 'Oh! and her blood sugar is around 600.' This nurse then replied, 'Send her out.' (LPN #6) then replied, 'Well I gave her Levemir for her sugar.' I again stated, 'Send her out.' (LPN #6) walked to her computer to print off (R5's) paperwork for transfer. (R5's) brother was in her room. When (LPN #6) stated, 'She has only 1 or 2 medications, so I didn't print it off.' This nurse then went to computer and there were no medications under (R5's) orders. This nurse stated to EMTs (Emergency Medical Technicians) that patient 'does not have any medications on her orders.' This nurse stated, 'I don't know of any medications being administered, other than Levemir (LPN #6) gave her.' This nurse then left the room and the unit. Another statement signed by LPN #7 (no signature date) documented, To Whom it may concern: I, (name of LPN #7), had no interaction with nurse on unit 2, until 1020 PM on May 12th 2024. Said nurse on unit 2 (RN #2) approached the nurses station on unit 1 @ 1020 PM regarding her relief. On call nurse (LPN #8) was notified and there was no other interaction after 1030 PM.- Regarding (RN #2) (the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24). LPN #7 was not available for interview during the survey. A statement signed by LPN #8 (R5's unit manager) on 5/13/24 documented, On Monday 5/13/24, I came in to relieve the nurse (LPN #6) because she needed to leave by 630 am. (LPN #6) gave me report on the unit, she told me that she sent (R5) out because of the pain she was having. I asked her did she let anyone know. She stated no it was late it was 1 am. I then stated two residents went to the hospital on your watch, on call should have been called. I explained that and proceeded to take report. A statement signed by LPN #8 on 5/15/24 documented, On 5/12/24 at 12:32 am, nurse (LPN #5) text my phone to state the nurse during the day did not get the meds approved at 2 pm when the resident was admitted on 5.11.24. (LPN #5) stated she called (name of physician group) on call to get the meds verified but the on call (name of nurse practitioner) refused to verify the meds because she stated she doesn't verify meds after 8pm. Once I woke up to the text at 0738 (7:38 a.m.) I contacted (LPN #5) and she explained what she wrote in her text. I then called (name of medical director) explaining what happened, he stated this was not the first time on call has done this that he would be reaching out. Resident meds still needed to be verified, (name of medical director) stated to call on call and have them verify the meds. (Name of medical director) was contacted by me on 5/12/24 at 0838 (8:38 a.m.). This writer then called the building x (times) 4, no one answered. I then called the housekeeper supervisor to check all phones in the building because no one was picking up, she took phone to nurse. I told (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24) to place the orders in (name of computer system) because she stated to me that (RN #3), the nurse on unit one already verified the meds. (RN #2) stated she had one more resident to give meds to and she was going to put the orders in. LPN #8 was not available for interview during the survey. On 9/17/24 at 2:10 p.m., a telephone interview was conducted with LPN #5. LPN #5 stated she could not recall details and to refer to her note. RN #2 was not available for interview during the survey. A printed text message from LPN #6 (the nurse who sent R5 to the hospital on the night of 5/12/24) to ASM (administrative staff member) #2 (the Director of Nursing) (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8) and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). Another printed text message from LPN #6 to ASM #2 (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8) and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). ASM #2, I have been waiting for a phone call from you. Since I haven't, I am going to write an incident report to my agency and I will report you to the VA (Virginia) board of nursing. The patient I sent to the hospital hadn't got her insulin for a day and a half because the dr (doctor) on call refused to verify the meds since (R5) didn't return to the facility while she was on call . LPN #6 was not available for interview during the survey. A statement signed by ASM #2 (the Director of Nursing) (no date) documented, On 5/13/2024, 11 a.m. I called (name of nursing staff agency) to request (RN #1's) telephone number and reported Nurse's failure to initiate an admission nor verify medications to treat resident. Resident arrived at 2pm. Staffing agency, stated that they would contact Nurse and have her return my call. Upon return call, I inquired of the reason (RN #1- the nurse who cared for R5 when the resident was re-admitted on [DATE]) did not initiate the admission process for the readmission. Nurse verbalized, she was extremely busy. 'I had to discharge a resident and was not sure of the process, and that the Unit Manager (who was on call and in the building) assisted her with printing discharge paperwork. 'I am not familiar with your version of (name of computer software), I use (name of computer software) at another facility, and however I am more familiar with (name of another computer software). I did ask (LPN #7) on the other unit, what I needed to do for the admission, and she told me the resident was a regular resident and all the medications for her were on the cart.' I went on to ask the Nurse had she received a discharge packet from the Medical transportation personnel, her response was, 'yes.' I continued by referencing her admission note and resident's script upon her return and inquired about the failure to call MD (medical doctor) for verification of orders. Nurse (RN #1) stated, she was unaware of the need to call since, she was told her medications were on the cart. I followed up by asking, Did you see a MAR (medication administration record) for the resident? 'No.' Did you ask the Unit Manager for assistance? 'No.' When you completed your assessment [sic] the resident and noted the script for Gabapentin (used to treat seizures and pain), why did you not input the new script? 'I continued to pass the other medications to the other residents.' Have you ever performed an admission? 'Yes, your system is different, and in (name of another computer system) after putting the resident in the system the admission assessments automatically populates [sic].' 'I informed the oncoming nurse that I had an admission but did not finish it and she said she would finish it, I offered to stay if she would walk me through the process, but she told me she would complete it.' Interviewed (LPN #5- the nurse who cared for R5 during the 7:00 p.m. to 7:00 a.m. shift 5/11/24 into 5/12/24), via telephone. She verbalized she did inform the nurse that she would complete the admission, but initially was not aware of that the medications were not transcribed nor verified. (LPN #5), during her medication pass noted (R5) did not have a MAR, immediately after her medication pass, she made an attempt to call to verify orders, and after speaking with the On call Physician, who would not verify the orders. She texted the On Call Nurse. (LPN #5) was asked, why she did not call (name of the medical director) and she verbalized that she was not aware that she could since there was an On Call system in place. I educated (LPN #5), to call instead of text the On Call Nurse management team member or myself, and in cases of this importance (name of the medical director) can be called. (LPN #5) added that she did inform the oncoming Nurse to call to have the orders verified. However, the oncoming Nurse stated, 'I will not be doing that because it [sic] Mother's Day.' Called (name of nurse staffing agency), informed that of (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24), failure to complete Medication Administration Record documentation, failure to follow up on a readmission, and failure to complete skilled documentation. Interviewed via telephone, (RN #2), stated she 'thought' she signed off her medications, 'I was constantly on the cart, tending to residents, answering questions for family members, and made attempts to control (R5's) pain since the resident only came back with gabapentin. They called in Tramadol (used to treat pain) to the pharmacy and it did not come in, then I got an order for Tylenol 1000 mg (milligrams) and gave it to resident.' I inquired of why the orders were not transcribed on the MAR nor documented in the system and was she aware that (R5's) medication were not verified? 'There was a lot going on and I planned to do it.' Why did you did [sic] not call the On call Nurse for assistance? 'I do not have anyone's number and like I said it was a lot going on.' (RN #2) was informed that there is a calendar at the desk with all On Call Nurses numbers attached. (RN #2) said she did not have time to look for anyone's numbers, but she did ask (LPN #7) for assistance. On 9/17/24 at 9:33 a.m., an interview was conducted with LPN #4 (the current unit manager). LPN #4 stated that when a resident is re-admitted from the hospital, he or she returns with a package that contains a medication list and discharge instructions, and the admitting nurse should call the doctor to verify the medication list. LPN #4 stated sometimes the doctor changes medication orders and after medications have been verified, the nurse should put all orders into the computer system. LPN #4 stated that after orders are put into the computer system, they are transmitted to the pharmacy and transcribed onto a MAR. LPN #4 stated she would not stop in the middle of a medication pass to complete this process, but it should be done as soon as the resident arrives. LPN #4 stated, That's the first thing they should do because we need the meds. LPN #4 stated if the physician or nurse practitioner will not verify medications upon re-admission, the admitting nurse should call the medical director and inform the Director of Nursing. On 9/17/24 at 10:46 a.m., an interview was conducted with ASM #2 (the Director of Nursing). ASM #2 stated that when a resident is re-admitted , the nurse should greet the resident, make sure the resident is comfortable, then go to the desk and open the packet of information and orders from the hospital. ASM #2 stated the nurse should enter/transcribe the orders into the queue in the computer system then verify the orders with the physician because the physician may want to change the orders. ASM #2 stated that after the orders are verified with the physician, the nurse should make the orders active in the computer system so the orders are activated onto the MAR and sent to the pharmacy. ASM #2 stated she was not made aware of the above incident regarding R5 until the resident was being sent back to the hospital on [DATE] into 5/13/24). ASM #2 stated it was the middle of the night and she received a phone call from R5's brother. ASM #2 stated the facility staff could not manage R5's pain. ASM #2 stated R5's brother said R5 was in significant pain and had not received any pain medications in over 24 hours. ASM #2 stated that at that point, all she could do was agree that pain medications should have been obtained for R5 then she called the facility staff to make sure they sent R5 to the hospital and documented a note. ASM #2 stated she could not recall what facility staff she talked to or if she was made aware of R5's blood sugar. ASM #5 stated that when R5 was re-admitted to the facility on [DATE], the first nurse should have queued the medications in the computer system, called the physician to verify the medications, sent the medication orders to the pharmacy, and if the resident was in pain or required insulin, the nurse should have contacted the pharmacy and obtained medications from the box in the facility. ASM #2 stated that if the nurse didn't know what to do, she should have called the on-call nurse or ASM #2. ASM #2 stated that if the nurse practitioner refused to verify the medications, then the nurse should have notified her so she could have notified the medical director. On 9/17/24 at 11:23 a.m., an interview was conducted with ASM #6 (the medical director). ASM #6 stated the responsibilities of the on-call physician or nurse practitioner are to take care of the patient, verify orders, and send the pharmacy an e-script (electronic prescription) if needed. In regard to the above incident involving R5, ASM #6 stated that if he recalled, there were errors on multiple sides. ASM #6 stated the orders should have been called in to the on-call nurse practitioner as soon as R5 arrived to the facility but it was the responsibility of the on-call nurse practitioner to verify orders and send e-scripts whenever called, regardless of the time. ASM #6 stated, It is our responsibility to make sure it happens with as little delay as possible. ASM #6 stated he should have been notified when the on-call nurse practitioner refused to verify R5's orders but he was not notified until the next day. ASM #6 stated the on-call nurse practitioner does not round at the facility and is only on-call for the group, but he escalated the incident to the chief medical officer because the patient actually came to some harm and had to go the emergency room for a lack of order verification and pain management. On 9/18/24 at 1:11 p.m. another interview was conducted with ASM #6. ASM #6 was made aware of the statement signed by LPN #8 on 5/13/24 that documented he (ASM #6) was notified on 5/12/24 at 8:38 a.m. ASM #6 stated he went back through his phone records. ASM #6 stated that during the morning on 5/12/24, LPN #8 made him aware that R5 was admitted at 2:00 p.m. on the previous day and the medications were not called to the on-call nurse practitioner until midnight and the nurse practitioner declined to verify the medications because she thought they should have been called to her earlier in the day. ASM #6 stated he told LPN #8 to call the on-call nurse practitioner back since it was not after 8:00 p.m., and if the nurse practitioner did not verify the medications, call him back. ASM #6 stated he was not notified again until R5 was sent to the hospital. On 9/17/24 at 1:25 p.m., ASM (administrative staff member) #1 (the interim administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Physician/Provider Orders documented, admission ORDERS: All information received from the referring facility or agency shall be reviewed. 1. Transcribe all orders from the transfer form to the facility admission physician order form. 2. The attending physician shall review and confirm the orders. References: (1) A blood sugar test measures the amount of a sugar called glucose in a sample of your blood. If you had a fasting blood glucose test, a level of 70 to 99 mg (milligrams)/dL (deciliter) is considered normal. If you had a random blood glucose test, a normal result depends on when you last ate. Most of the time, the blood glucose level will be 125 mg/dL or lower . (2) Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. This information was obtained from the website: https://medlineplus.gov/ency/article/000320.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #74 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnosis included but were not limited to, Cellulitis of left lower limb and Type 2 Diabetes Mellitus without complications. Resident #74's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 11/26/2020 was coded with a BIMS (Brief Interview for Mental Status) score of 09 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #74 as requiring supervision with setup help only with eating, limited assistance of 1 with bed mobility, extensive assistance of 1 with transfer and personal hygiene and total dependence of 1 with bathing. On 07/06/2021 review of Resident #74's clinical record revealed the following: admission Progress Note dated 11/20/2020 15:10 was reviewed and revealed the following: .has MASD (Moisture Associated Skin Damage) to the buttocks area with redness and excoriation, with an open area to the rt (Right) buttocks 0.5 x 1 x 0 MD (Medical Doctor) notified, moisture barrier cream applied . Braden: 13.0 Pressure / Non Pressure Skin Assessment Progress Note dated 11/20/2020 15:10 was reviewed and revealed and is documented in part, as follows: Note Text: Wound type is MASD Wound Location buttocks Length (cm) (Centimeter) 0.5 Width (cm) 1 Depth (cm) 0 Area is community acquired, no skin impairment was present on admission. 11/20/2020 Drainage type: No Drainage Wound bed appearance is Pink No odor Periwound appearance is Pink. Area is a new wound. Pain levels 0 11/20/2020 12:00 AM Treatment: moister [sic] barrier cream waiting on further orders from MD. Review of Physician Orders revealed the following: ORDERS Admit To Colonial Health & Rehab Diagnosis: CHF (Congestive Heart Failure) Allergies: Bactrim, Cymbalta, Amoxicillin, Latex Diet: Cardiac Diet Code Status: DNR (Do Not Resuscitate) / DNI (Do Not Intubate) Verified By (Name of Medical Doctor) Other #1. 11/20/20 Medications Treatments Wound MD eval (Evaluate) and treat. Review of orders did not evidence a treatment order for buttocks or sacrum. On 07/07/2021 requested copies of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for November 2020 and December 2020 and Braden scores for Resident #74. On 07/07/2021 requested copy of Resident #74's wound measurement from admission to discharge. Copy of Weekly Wound Assessment v1 - V5 was received. Review of assessment revealed the following: Effective Date: 11/20/2020 15:10 admission: [DATE] 1. Wound Overview 1. Wound Type 10. Other; 1a. Other Wound Type MASD; 2. Wound Location: buttocks; 3. Length (cm) 0.5; 4. Width (cm) 1; 5. Depth (cm) 0; 6. Location Where Wound Was Acquired? 2. Community Acquired 2. Wound 1. Was the skin impairment present on admission 1? Yes; 3. Date Wound Identified 11/20/2020 6. Wound Bed Appearance 1. Pink; 8. Periwound Appearance 1. Pink; 10. Wound Status 1. New Wound; 4. Comments and Treatment 2a. Date and Time Physician Notified: 11/20/2020 00:00; 3. Treatment moister [sic] barrier cream; 4. Comments waiting on further orders from MD. On 07/07/2021 at 6:30 p.m., received copies of Resident #74's MAR and TAR for December 2020 from the Director of Nursing (DON). The Director of Nursing stated, We are still looking for November MAR and TAR. Resident #74's TAR received for the Month of December was reviewed on 07/07/2021 and revealed the following: Medications - Calmoseptine after each incont (Incontinent) episode. In the column under HOUR, Day, Night is documented. Resident #74's admission / readmission Evaluation - V 2 completed on 11/21/2020 was reviewed on 07/07/2021 and revealed the following: Skin Risk Score: 13 Skin Risk Category: Moderate risk. On 07/07/2021 review of Physician / PA (Physician Assistant) / NP (Nurse Practitioner) Progress Note dated 11/23/2021 14:19 in Resident #74's clinical record revealed the following: genitourinary: genitals unremarkable, there is some moisture associated skin damage with erythema on most of the buttocks area it's completely covered with calmoseptine there is some mild skin breakdown on the right buttocks it only appears to be about one or 2 cm but I could not get the calmoseptine off at this time she said it was too uncomfortable and wish to just leave it on. Did not see any other lesions. Review of Resident #74's Nursing Progress Note dated 11/24/2021 revealed and is documented in part, as follows: Note Text: Wound Doctor in to see patient today. MASD to bottom healing, no open areas just redness, barrier cream and calmoseptine applied. Resident #74's Braden Scale Pressure Ulcer Risk Assessment with an Effective date of 11/27/2021 was reviewed on 07/07/2021 and revealed the following: Braden Score: 18 Braden Category: Low Risk. On 07/07/2021 Resident #74's Bi-Weekly Skin Check 1 with a date of 11/29/2021 was reviewed and revealed the following: 1. Does the resident have current Skin Issues 1. Yes Document current Skin Issues Site 53) Sacrum Description redness. On 07/07/2021 Resident #74's Bi-Weekly Skin Check 1 with a date of 12/2/2021 was reviewed and revealed the following: 1. Does the resident have current Skin Issues 1. Yes Document current Skin Issues Site 53) Sacrum Description redness. On 07/08/2021 at approximately 10:00 a.m., an interview was conducted with (Name of Doctor) Medical Doctor (MD) Other #6. When MD was told that surveyor had a couple questions for him regarding Resident #74, MD stated, I think I saw her maybe one time. When asked about Resident #74's admission orders, MD stated, We order what the hospital recommends, whatever the hospital ordered. When asked what the process for ordering resident medications is, MD stated, The nurse sends the orders from the discharge summary to the doctor, these are the medicines the hospital placed the patient on. If the doctor is not in the facility the staff would have to read the orders from the Discharge Summary over the telephone and not all medications are approved for different reasons. MD stated the last time he saw Resident #74 was December 2. MD stated, She had calmoseptine on every time I saw her. When asked was Calmoseptine an acceptable treatment for her buttocks, MD stated, Yes, it is a barrier cream. MD also stated, It keeps urine and poop off of the skin and it makes it slower for the skin to dry out. Review of Resident #74's clinical record for the period of 11/20/2020 through 11/30/2020 revealed documentation that staff applied barrier cream and /or Calmoseptine to resident on 11/20/2020, 11/23/2020 and 11/24/2020. There is no evidence that the resident was provided treatment to wounds consistently or had a wound treatment order during this time. On 07/08/2021 Resident #74's hospital records was reviewed and revealed the following: (Name of hospital) Emergency Department Time of Arrival: 12/03/20 0806 ED (Emergency Department) Provider Note Physical Exam Skin: Comments: Stage II decubitus ulcer in the sacral area this appears overall to be well - healed with some surrounding areas of erythema and stage I ulceration.; Progress Notes by (Name of Nurse) RN (Registered Nurse), Other #7 at 12/4/2020 0203 Skin Image 5: Large area skin breakdown with several open areas. Non-blanching redness. Received patient from ED alert and oriented . Skin assessment completed, skin care provided. (Review of Skin Image Diagram indicates 5 is in the sacral region.) On 07/08/2021 at approximately 3:45 p.m., an interview was conducted with the Director of Nursing. When asked do you have any other wound measurements or Weekly Wound Assessments for Resident #74 buttocks or back, Director of Nursing stated, No. When asked do you have the MAR and TAR for November 2020, DON stated, We cannot find the MAR and TAR for November. When asked what is the MAR and TAR, DON stated, They are records to document what medications were administered and what treatments were given. When asked do you have the Physician Order Summary (POS) for November 2020, DON stated, I don't see a treatment for the buttocks on the POS. When the DON asked for a copy of the POS provided a copy of the Physician admission orders. When asked were there any orders written for treatments to the buttocks after the admission order, DON stated, No, I don't see anything in here. When asked should the resident had a treatment ordered for her MASD and wound on her buttocks, DON stated, Yes. When asked what your expectations of nurses are when a resident has a wound, DON stated, See if treatment came over from the hospital and if it did not then to obtain a treatment order from the physician. When asked why should wounds and impaired skin integrity have a treatment, DON stated, to help promote healing. On 07/08/2021 at approximately 6:00 p.m. Administrator and Director of Nursing was informed of findings at pre-exit meeting. The facility did not present any further information about the finding. Complaint Deficiency Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to obtain a treatment for pre-existing pressure ulcer* that had later declined to an unstageable (1) pressure ulcer for one of 41 residents in the survey sample; Resident #35 AND failed to provide treatment and services to promote the healing of a pressure sore for one of 41 residents; Resident #74. *Pressure Injury (ulcer) - A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. https://npuap.org/page/PressureInjuryStages. The findings included: Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to chronic heart failure, spinal stenosis, and chronic embolism and thrombosis of unspecified deep veins of lower extremity (bilateral). Resident #35's most recent MDS (Minimum Data Set Assessment) was a quarterly assessment with an ARD (assessment reference date) of 5/20/21. Resident #35 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status exam). Resident #35 was coded in Section M (Skin Conditions) as having a stage 4 (2) pressure ulcer. On 7/6/21 during an interview with Resident #35; Resident #35 had stated that he had come into the facility with a pressure ulcer but that he didn't feel that the facility was doing dressing changes like they should have been and that the wound had worsened. Review of Resident #35's facility admission note dated 12/9/20 documented in part, the following: Resident Arrival Date and Time: 12/09/2020 6:00 PM .Open area to coccyx present 1.5 X 2.5 cm (centimeters) x 0.1 cm .Braden: 13.0 (3). The next note dated 12/9/20 documented the following: Note Text: Wound type is pressure. Stage: 2 (4) Wound Location coccyx. Length (cm) 1.5, Width (cm) 2.5, Depth (cm) 0.1 Area is community acquired. Skin impairment was present on admission. 12/09/2020 Drainage type: Serosanguineous Drainage Small Drainage, Wound bed is Red No odor, Area is a new wound. Pain Level is 0 Family notified 12/10/2020 9:00 AM. Physician Aware: 12/10/21 .Treatment: (No treatment was documented). Review of a physician note dated 12/10/20 revealed that the physician was aware of Resident #35's wound to his sacral area. The following was documented: .new sacral lesion about 2 x 1 cm stage II it was noted by the staff . There was no evidence that orders for a treatment were obtained. Review of the physician order summary for December 20201 revealed that an order for the sacral wound was not put into place until 12/14/20 (5 days later). The following was documented: Treatment as follows: cleanse sacrum area with normal saline, apply skin barrier wipe to periwound area, apply Dermagel Hydrogel Sheet dressing, cover with gauze and tape or non-adherent dressing. Change every three days and prn (as needed). There was no evidence on the December 2020 TARs (Treatment Administration Record) or MARS (Medication Administration Record) that the 12/14/20 order was implemented. On 12/12/20 there was evidence that the primary physician had conducted a partial assessment on the sacral wound on 12/12/20. The following was documented in part, a sacral stage II skin breakdown about 1 x 2 cm with no secondary infection cellulitis or tunneling . Description of the wound bed, periwound etc. was not mentioned in the above assessment. Review of a weekly wound assessment dated [DATE]; revealed that Resident #35's sacral wound had deteriorated. The following was documented: Wound Type: Pressure. Stage: Unstageable. Wound Location: sacrum. Length: 7 (cm) by Width (13 cm) Depth nonmeasure .was skin condition present upon admission? Yes .Drainage: Serous. Drainage Amount: Scant. Odor. None. Wound Bed appearance: necrotic .Odor: none. Peri wound appearance: Red .DRESSING TREATMENT PLAN. Primary Dressing(s) Dakin's solution (5) apply once daily. Santyl (6) apply once daily. Secondary Dressing(s) Gauze Island (w/bdr) apply once daily. Peri Wound Treatment Skin prep apply once daily .This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Review of the Resident #35's December 2020 MAR (Treatment Administration Record) revealed that this order was implemented on 12/17/20. Review of a note by the wound care physician dated 12/22/20 documented in part, the following: At the request of (Name of physician) a thorough wound care assessment and evaluation was performed today. He has an unstageable (due to necrosis) sacrum for at least 8 days in duration. There is light serous exudate .Wound Stage: 8.0 x 10.0 x Not Measurable cm. Periwound radius: Odor .Thick adherent black tissue: 50 % (percent) Thick adherent devitalized tissue: 20 % Granulation tissue: 20 % Skin: 10 % (percent). Wound progress: Deteriorated. Review of Resident #35's care plan dated 12/9/20 through 6/2/21 revealed a skin integrity care plan was not put into place until 12/30/21. The following was documented, in part: Resident has impaired skin integrity- Unstageable PU (pressure ulcer) to sacrum present on admission .administer treatments as ordered, Encourage (Name of Resident #35) to turn and reposition while in bed, monitor nutritional status. Consult dietician. Review of Resident #35's December 2020 POS (Physician Order Summary) also revealed that no skin prevention measures were put into place until 12/16/20 when he was ordered an alternating pressure mattress and double protein meat from the dietician. On 7/8/21 at 10:00 a.m., an interview was conducted with LPN (Licensed practical nurse) #1, a nurse who worked with Resident #35 on occasion. When asked who was responsible for assessing a wound upon admission into the facility, LPN #1 stated that it was the floor nurse who was responsible for measuring the wound and providing a description of the wound. LPN #1 stated that LPNs could not stage but that an RN could stage a wound. LPN #1 stated that if the resident is not admitted with a treatment order on the hospital discharge instructions, it is up to the nurse to call the MD (medical doctor) for an order. LPN #1 was shown the admission note for Resident #35 on 12/9/21. LPN #1 was then shown the December 2020 POS (physician order summary) and the December MARs and TARS for 2020. LPN #1 confirmed that she did not see that a treatment was put into place once his wound was identified upon admission as a stage two. When asked the consequence for not doing a dressing to an identified stage two ulcer, LPN #1 stated that the wound could get worse. LPN #1 was then shown that on 12/15/20 (Next weekly wound assessment) Resident # 35's wound had gotten bigger and was found to have necrotic tissue to the wound bed. LPN #1 stated, Yes, it looked like it had deteriorated. When asked what necrotic tissue was, LPN #1 stated that necrotic tissue was dead tissue that was black in color. LPN #1 stated that necrotic tissue has to be debrided in order for healing to occur. On 7/8/21 at 12:16 p.m., an interview was conducted with RN (Registered Nurse) #2, the unit manager for unit one and two. When asked if nursing staff were expected to assess and obtain a treatment order for a newly admitted resident who is admitted to the facility with an existing pressure ulcer, RN #2 stated, Yes, I expect the nurses to assess get a treatment order for that wound. When asked the consequence if an order for a treatment is not obtained for a pressure ulcer, RN #2 stated that it could lead to the wound deteriorating. When asked what necrotic tissue meant to the wound bed, RN #2 stated that necrotic tissue was dead tissue. RN #2 stated that if necrotic tissue is in the wound bed, the wound will not heal until it has been removed. When asked if necrotic wounds are considered advanced stage wounds, RN #2 stated that they were. This writer had discussed the above findings with RN #2. RN #2 was asked to present any additional information regarding Resident #35's sacral wound. RN #2 was made aware that if this information was not found; this citation could lead to a serious scope and severity level. On 7/8/21 at 12:30 p.m., ASM #1, the Administrator was made aware of what was discussed with RN #2 and that documentation was needed to show that a treatment was put into place and implemented on 12/9/20 through 12/14/20 prior to the wound deteriorating. On 7/8/21 at approximately 3:00 p.m., RN #3, the MDS nurse presented Section M (Skin Conditions) of Resident #35's MDS assessment with an ARD date of 12/15/20. RN #3 stated that the look back period for this particular MDS was on 12/8/20 through 12/15/21. RN #3 stated that there had to have been an order in place if she had checked that Resident #35 was receiving dressings and ointments. The following was documented on this MDS and signed by the MDS nurse on 12/29/20: A. Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device: Yes; B. Formal Assessment: Yes. C. Clinical Assessment: Yes M0210. Unhealed pressure Ulcers/Injuries: Yes. M0300. Current number of unhealed pressure ulcers/injuries: F1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: (1) .F2. Number of these unstageable pressure ulcers that were present upon admission or reentry: (1). Section F2 was inaccurate as it was documented in the clinical record that Resident #35 was admitted to the facility with a stage two ulcer. Further review of the Section M of Resident #35's MDS documented the following: .Application of nonsurgical dressing (with or without topical medications) other than to feet: Yes. H. Application of ointments medications other than to feet: Yes. There was no still no evidence that a treatment order was obtained and implemented after Resident #35 was admitted to the facility with a stage two pressure ulcer; AND there was no evidence that Resident #35 was receiving any type of ointment or barrier cream. On 7/8/21 at 3:15 p.m., a phone interview was conducted with the nurse who admitted Resident #35 on 12/9/20. She could not recall if Resident #35 had been admitted with a wound and if an order was obtained or not. On 7/8/21 at 4:00 p.m., ASM #1, the Administrator; ASM #3 and #4 the Corporate Nurses were made aware of the concern for harm. ASM #4 stated that they still could not find the treatment order for the stage II wound during 12/9/20 through 12/14/20 or a TAR showing that the order was implemented. ASM #4 stated that the orders and TAR were probably written on paper back when they were doing paper charting. ASM #4 stated that the 12/15/20 MDS however reflected that Resident #35 had an order in place because the MDS RN had signed and locked the MDS which indicated that all information on the MDS was accurate. This writer informed ASM #4 that the signature means that the section was completed, not that the information was accurate. On 7/8/21 at the exit conference held at 6:30 p.m., ASM #4 stated that she was still looking for TAR and order. This information could not be presented prior to exit. No further information was presented prior to exit. Facility Policy titled, Pressure Injury Prevention and Treatment Policy, documents the following: Resident's will be assessed for pressure injury risk on admission, quarterly, and with significant change of condition using the Braden Scale for Predicting Pressure Ulcer Risk. Wounds identified will be assessed initially and at least weekly thereafter, until closed. To include the following elements: Location and stage Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth and the presence, location and extent of any undermining or tunneling/sinus tract; Exudate, if present: type (such as purulent/serous), color, odor, and appropriate amount; Pain, if present: nature and frequency (e.g., whether episodic or continuous); Wound bed: Color and type of tissue/character including evidence of healing (e.g. granulation tissue, maceration) as appropriate; Appearance of surrounding tissue; Any evidence of infection If a PU (Pressure Ulcer)/Pressure Injury) fails to show some evidence of progress towards healing within 2-4 weeks, the area and the resident's overall clinical condition will be reassessed. B. Treatment: Pressure injuries identified will be documented and orders obtained from providers for treatment. C. Monitoring: At least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI will be documented. At a minimum, documentation will include the elements listed in Section A. D. Notification: The facility will notify family/resident representative[s] and the provider of any newly acquired or worsening pressure injuries and any changes in treatment[s]. (1) Unstageable pressure ulcer- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (2) Stage 4 pressure ulcer- Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (3) The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer development .The Braden Scale is a summated rating scale made up of six subscales scored from 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6-23 (one subscale is scored with values of 1-3, only). The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levels of risk for pressure ulcer development. This information is taken from the website https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/LNC_BRADEN/ (4) Stage 2 pressure ulcer- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (5) Dakin's solution is used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores. This information was obtained from: https://www.webmd.com/drugs/2/drug-62261/dakins-solution/details. (6) Santyl- *SANTYL® Ointment is an FDA-approved active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level. This works to free the wound bed of microscopic cellular debris, allowing granulation to proceed and epithelialization to occur. (<http://www.santyl.com/about>)