**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that parenteral medications were administered consistent with professional standards of nursing practice for 1 of 1 resident (R29) reviewed for parenteral medications. R29 was readmitted to the facility on [DATE] with a midline for IV (intravenous) antibiotic treatment following a diagnosis of sepsis secondary to urinary tract infection with E. coli bacteremia (bacteria in the blood). On 7/27/24, LPN P (Licensed Practical Nurse) attempted to flush the midline and was unable to, noting that some of the normal saline ran down R29's arm. LPN P reported this to RN O (Registered Nurse) around 2:20 PM on 7/27/24. RN O did not complete an immediate assessment and when he did complete an assessment, he found the line to appear infiltrated (catheter delivering fluid into tissues instead of the vein). RN O attempted to remove the catheter without a physician order, and the midline broke, retaining a piece of catheter in R29's left arm. R29 was then sent to the emergency room at 11:30 PM that night, 9 hours after the initial concern was raised by LPN P. R29 was found to have a 10 cm (centimeter) length of catheter retained in her upper arm that required a surgical procedure to remove it. After several failed attempted procedures and a long referral process, R29 finally had the catheter removed on 10/7/24. The facility's failure to monitor and document monitoring of the midline site, to measure and record the measurement of the midline, to notify the provider following LPN P's concern of the midline not flushing, to complete a timely RN assessment following notification of a problem with the midline, and conduct removal procedures according to policy and current standards of practice caused R29 to retain 10 centimeters of midline catheter within her brachial vein. This put R29 at risk for pulmonary embolism (blockage of lung vessels by the catheter), stroke, or death. This created a finding of Immediate Jeopardy beginning on 7/27/24. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the finding of Immediate Jeopardy on 11/11/24 at 1:23 PM. The immediacy was removed on 11/13/24 and continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: The facility policy titled, Intravenous Therapy, dated 10/1/22, states in part: .Compliance Guidelines: . 8. IV sites are changed every seventy-two (72) hours unless otherwise ordered by the physician, if the site becomes infiltrated, or if the resident exhibits signs and symptoms of phlebitis. 9. In the event an IV is left in place longer than seventy-two hours, IV site care will be done every twenty-four (24) hours . 13. IV sites are checked every shift or as per facility policy and PRN (as needed) for signs and symptoms of infection or inflammation .14. The nurse will assess for associated risks due to IV fluid administration such as: a. infiltration b. bruising c. embolism (air or blood) d. phlebitis . 15. IV documentation is recorded in the nurses' notes and/or Medication Administration Record. 16. The nurse will notify the practitioner to assess the need for continuation of the catheter if not being used for IV fluids or medication and will discontinue as per the practitioner's order . The facility policy titled, Midline Catheter Flushing-Lock-Removal, dated 11/28/23, states in part: Policy: It is the policy of this facility to ensure that midline catheters are flushed, locked and removed consistent with current standards of practice . Compliance Guidelines: . 2. Midline catheters will be flushed and aspirated for blood return prior to each infusion to assess catheter and functionality and prevent complications . 5. The catheter will be locked after the final flush to prevent catheter occlusion if used intermittently. If it is a multilumen catheter, all lumens must be flushed regularly . 7. The facility will use a flush such as a heparin flush solution or preservative-free normal saline solution to lock the catheter as per facility protocol. 8. Syringes no smaller than 10 mL (milliliters) should be used when assessing patency to avoid catheter damage . 10. Midline catheter removal will be performed by the practitioner or nurse in accordance with facility policy and your state's nurse practice act. 11 . Obtain a physician's order for removal. Removal: 1. Verify the physician's orders . 6. Place resident in sitting or recumbent position. 7. Carefully remove the dressing and dispose in appropriate receptacle. 8. Remove stabilization device or sutures, if present . 10. Hold sterile gauze over insertion site and with dominant hand remove the catheter using gentle, even pressure . 11. Have the resident perform the Valsalva maneuver unless contraindicated, or exhale as the last segment of the catheter is withdrawn to prevent an air embolism. 12. Apply pressure to the site with gauze for about 30 seconds or hemostasis is achieved. 13. Apply a petroleum-based ointment to the exit site and cover with an occlusive gauze dressing or a transparent semipermeable dressing for at least 24 hours. 14. Label the dressing with date and initials. 15. Encourage resident to lie flat or reclining for at least 30 minutes to reduce risk for air embolism. 16. Inspect the catheter to ensure that the tip is intact and not damaged and entire length of catheter has been removed . 20. Document the procedure . According to the National Library of Medicine, midline peripheral catheters have a large catheter (16-18 gauge) that allows for rapid infusions. Midline catheters are typically inserted into the basilic, cephalic, or brachial veins of the upper arm with the proximal tip placed near the level of the axilla (armpit). They are much longer and inserted deeper than a peripheral IV (intravenous access), but do not extend into a central vessel, so are not considered a central line. (Source: https://www.ncbi.nlm.nih.gov/books/NBK594499/) According to the Center for Disease Control and Prevention's (CDC) recommendation for catheter education, training, and staffing, healthcare personnel should be educated regarding maintenance of intravascular catheters. Periodic assessment of knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters should be conducted. Additionally, designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. The CDC also recommends evaluation of the catheter insertion site daily by palpation to discern tenderness and by inspection. They also recommend removal of peripheral venous catheters if the patient develops signs of phlebitis (vein inflammation), infection, or a malfunctioning catheter, along with promptly removing any intravascular catheter that is no longer essential. The CDC's recommendations for dressings include not submerging the catheter site in water. (Source: https://www.cdc.gov/infection-control/hcp/intravascular-catheter-related-infections/summary-recommendations.html) R29 was admitted to the facility on [DATE], with diagnoses that include, in part: encounter for orthopedic aftercare, chronic obstructive pulmonary disease, type 2 diabetes mellitus, congestive heart failure, partial traumatic amputation of right foot, and acute osteomyelitis, right ankle and foot. R29's most recent Quarterly Minimum Data Set (MDS) with a target date of 9/6/24, documents a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates the resident is cognitively intact. On 7/17/24, R29's Hospital Discharge paperwork states that she was admitted for sepsis secondary to a urinary tract infection with E. coli bacteremia. While in the hospital, the resident had a midline placed in her left upper arm for antibiotic administration. On 7/20/24, R29 was discharged from the hospital and readmitted to the facility with the midline in place for continued antibiotic administration. NP FF (Nurse Practitioner) wrote a note with a date of service of 7/21/24 with an assessment and plan for history of UTI (urinary tract infection) and sepsis is to continue meropenem (antibiotic) for a total of a five-day course and to monitor for any signs of infection recurrence or complications. R29's Physician Orders for July 2024, state in part: Ertapenem Sodium Injection Solution Reconstituted 1 GM (Gram) (Ertapenem Sodium) Use 1 vial intravenously in the morning for E. coli in blood (bacteremia) for 55 days Give intravenous via midline in LUE (Left Upper Extremity) Heparin Sod (Sodium) Lock Flush Intravenous Solution (Heparin Sodium (Porcine) Lock Flush) Use 5 cc (cubic centimeters) intravenously one time a day for Midline Left AC (antecubital space, space inside of elbow) Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 10 ml intravenously every day shift for Flush Midline before and after IV ABT (Antibiotic) administration. (Of note: The Medication Administration Record (MAR) and Treatment Administration Record (TAR) from July 2024, contains no documentation or orders regarding dressing changes, midline site assessment, measurement, or monitoring.) R29's Comprehensive Care Plan states in part: Focus: Potential for infection/complication r/t (related to): IV use for ABO (antibiotic) for bacteremia. Date initiated: 7/22/24. Goal: Will be free from signs and symptoms of infection. Date initiated: 7/23/24. Target Date: 12/10/24. Interventions: Administer IV fluids/medications per MD (medical doctor) order, Change IV tubing, dressings, and caps according to line type change schedule in IV order set or more frequently as needed. Monitor for infiltration. Monitor IV site for s/s (signs and symptoms) of infection: redness, inflammation, drainage, irritation to the vein. Notify physician of any abnormalities. PICC. All interventions initiated on 7/22/24. (Of note: The care plan lists the wrong catheter type and does not include basic midline site care such as protecting the Tegaderm or bandage when showering, changing the dressing, or maintaining a measurement of how long the catheter is from the site.) NP FF wrote a note with a date of service of 7/22/24 that states R29 reported midline IV site discomfort. The assessment and plan for the IV site discomfort is to continue to use the midline as it flushes without resistance and no erythema or swelling is present, monitor the site for any signs of infection or complications, provide patient education on proper care of the midline site. R29's Medication Administration Record indicates she was administered her prescribed Ertapenem (antibiotic) as ordered from 7/21/24 to 7/25/24. On 7/25/24 at 00:30 (12:30 AM), a progress note was written by LPN CC which states: Res (resident) continues to receive IV abt (antibiotic) as ordered for bacteremia. No adverse reaction noted. (Of note: No progress notes regarding resident's midline are written on 7/26/24) On 7/27/24 at 14:24 (2:24 PM), a progress note was written by LPN P which states: Writer went in to flush res (resident) mid line. Res mentioned that it might not flush, because last flush res had had went back down arm. Writer attempted a flush with scant amount of NS (normal saline) but NS just rolled down res arm instead. Writer updated [Name] RN O to assess IV. (Of note: There are no notes written about the previous flush attempt where the midline was not working correctly and the saline ran down R29's arm.) On 11/7/24 at 1:50 PM, Surveyor interviewed LPN P. LPN P indicated she was working on 7/27/24, but no longer works at this facility. LPN P stated that she gave report to RN O about 2:20 PM, regarding the midline not flushing. LPN P stated she can't remember any additional information about the incident. On 7/27/24 at 23:34 (11:34 PM), a progress note was written by RN O which states: Writer started process of removing midline from resident. Upon removal of dressing and assessment of skin, unable to locate midline lumen insertion point. Writer determines midline has broken off into vein, coinciding with earlier reports from dayshift LPN P [Name] that midline did not flush. Area cleansed, dressed with gauze and tape. On 11/6/24 at 4:35 PM, Surveyor interviewed RN O. RN O described the standard of practice for both administering IV medication and removing a midline. Surveyor asked RN O what R29's midline site looked like when he entered the room. RN O states that it looked swollen and bruised and appeared to be infiltrated, and that he was going to remove it. As he pulled the Tegaderm off, the catheter broke and some of the catheter was still in R29's skin. Surveyor asked RN O if he received any education or training from the facility prior to caring for R29's midline. RN O stated no. Surveyor asked RN O if he completed any competency checks prior to caring for R29's midline. RN O stated no. On 11/7/24 at 3:00 PM, Surveyor interviewed RN O for the second time. Surveyor asked RN O if he had obtained an order to remove the midline. RN O indicated he would never remove a midline without an order. Surveyor asked RN O who he obtained the order from. RN O stated he doesn't remember. Surveyor asked RN O if he obtained a telephone or verbal order, should that order have been transcribed into the electronic medical record. RN O stated yes, but that he was too busy trying to transfer R29 to the emergency department. Surveyor asked RN O what he did after the Tegaderm was removed and the piece had broken off. RN O indicated he covered the site with a 4x4 sterile gauze and tape and notified the provider immediately. (Of note: LPN P reported to RN O around 2:20 PM that R29's midline was not flushing. R29 was not assessed, provider was not notified, and R29 was not sent out until around 11:30 PM, 9 hours after discovery of the problem. Additionally, there is no record of an order being given to remove the midline.) On 7/27/24 at 23:32 (11:32 PM), a triage note was written by RN DD, who is employed by an outside hospital. This note states: The patient comes from [Facility Name] after the nurse was removing her midline and part of it was missing. The patient brought the external piece of the midline and states the internal part is still in her. The patient denies any pain to that area of her arm. On 7/28/24, an x-ray was taken confirming 10 cm of a linear radiopaque density is found in R29's left upper extremity. On 7/28/24 at 01:41 (1:41 AM), a note was written by DO (Doctor of Osteopathic Medicine) EE, who is also employed by an outside hospital. This note states in part: . She had a midline catheter placed so that she could complete her course of meropenem at home for her E coli bacteremia. This was stopped however yesterday when the catheter was flushed her arm swelled up. Then today the hub of the catheter broke off without the rest of the catheter coming with it. She presented today with x-ray findings of the catheter still in her arm. This note also indicates that DO EE attempted a sterile procedure utilizing local anesthesia to numb the area and an ultrasound to visualize the catheter. DO EE made an incision down to the brachial arterial sheath but was unable to identify the catheter in the brachial vein, and due to the risk to the brachial artery had to stop the procedure. On 7/28/24 at 03:53 (3:53 AM), hospital documentation shows R29 was transferred from one hospital to another outside hospital for further care and treatment. R29's discharge paperwork from the second outside hospital indicates that she was admitted from 7/28/24 to 7/30/24. Discharge diagnosis includes in part: vascular catheter issue s/p (status post) IR (interventional radiology) attempt to retrieve, which was unsuccessful. The hospital course indicates R29 reported that her midline had been flushing ok up until Friday (7/26/24) when the flush went all over. R29 also reported her midline seemed to flush fine on Thursday (7/25/24). Additionally, R29 reported that the line was to be discontinued yesterday (7/27/24) but when the RN took the band aid off, it was broken. Under the section labeled ED Course, it states in part: . IR attempted to retrieve under sedation, but unsuccessful. Per IR, she will need upper arm brachial exposure in the event of phlebitis or infection to perform a venotomy and removal of the catheter. The catheter will be very unlikely to [sic] move due to the thrombosed vein. Plan to keep in place and monitor for phlebitis or infection. Would recommend no IVs or BPs (blood pressures) to LUE (left upper extremity) . NP FF wrote a note with a date of service of 8/13/24. This note indicates an Assessment & Plan for left upper extremity pain and PICC line remnants [sic] of scheduling an appointment for vascular surgery to remove the remaining catheter and to continue to monitor the site for any signs of infection, erythema, discharge, swelling, or discoloration. NP GG's note from 10/7/24, indicates that R29 had the catheter removed on this date. On 11/7/24 at 10:40 AM, Surveyor interviewed NP FF. Surveyor asked if NP FF assessed and flushed the midline herself. NP FF stated she assessed the site but did not flush the midline. Surveyor asked NP FF if she gave an order to remove the midline. NP FF stated, I'm 100% sure someone did. Surveyor asked NP FF if she would expect staff to conduct dressing changes. NP FF indicated once every seven days or when soiled. Surveyor asked NP FF if she would expect staff to be doing measurements of the line to ensure the line wasn't migrating, which is current standard of practice. NP FF indicated she would not expect staff to measure the external line. Surveyor asked NP FF if she expects staff to document things like dressing changes or removal of the midline. NP FF stated she doesn't speak to staff expectations at the facility. On 11/7/24 at 11:57 AM, Surveyor interviewed R29. Surveyor asked R29 what her experience was like throughout this process. R29 indicated that initially she was ok since things were getting taken care of, however after she returned from the second outside hospital, she was experiencing a lot of pain and discomfort. She also indicated that this pain was worse than her normal chronic pain due to the unpredictability of pain occurrence. R29 described not knowing what kind of action or motion caused the pain so she was always surprised when it started hurting which made it worse. Surveyors requested all training, education, and competency records for all LPNs and RNs working in the facility for the past year. LPN CC last received training on managing intravenous devices on 10/5/24. A description of this training was obtained from the facility, and it does review vascular access devices, care of vascular access devices, and risks of vascular access devices. Documentation does not list any other dates this training was completed. Also of note, the facility provided a document titled, Medication Administration Competency Test that is undated. Surveyor notes only two questions that could be applicable specifically to midlines or central venous catheters and asks about heparin locks and using the SASH flushing method (Flush Saline, administer medications, Flush Saline, Administer Heparin). LPN CC has the question regarding heparin locks marked incorrect. Surveyor also notes these questions contradict each other, as the SASH method requires a heparin lock following each infusion, whereas the correct answer indicated for the heparin lock question requires this to only be done one time per day. Additionally, several documents titled, Licensed Nurse Competency were provided to Surveyor with the most recent date 2/24/24. Under the section titled, Medication Management, there are many topics including one titled, IV Therapy; no further specifics are listed, especially pertaining to midlines. No documentation of competency checks was provided regarding care of a resident with a midline. LPN P last received training on managing intravenous devices on 4/18/24. A description of this training was obtained from the facility, and it does review vascular access devices, care of vascular access devices, and risks of vascular access devices. Also of note, the facility provided a document titled, Medication Administration Competency Test that is dated 12/3/19. Surveyor notes only two questions that could be applicable specifically to midlines or central venous catheters and asks about heparin locks and using the SASH flushing method. LPN CC has the question regarding heparin locks marked incorrect. Surveyor also notes these questions contradict each other, as the SASH method requires a heparin lock following each infusion, whereas the correct answer indicated for the heparin lock question requires this to only be done one time per day. Additionally, several documents titled Licensed Nurse Competency were provided to Surveyor with the most recent dated 12/8/23. Under the section titled Medication Management, there are many topics including one titled IV Therapy; no further specifics are listed, especially pertaining to midlines. No documentation of competency checks was provided regarding care of a resident with a midline. (Of note: According to the Wisconsin Nurse Practice Act, N6.03(1), LPNs may only accept patient care assignments which the LPN is competent to perform and perform delegated acts beyond basic nursing care under the direct supervision of an R.N. or provider.) RN O also has a document titled Licensed Nurse Competency dated 8/2 with no year listed. Under the section titled, Medication Management, there are many topics including one titled, IV Therapy. RN O's records came with an undated guideline titled IV Competency without any facility designation or markings. This document contains topics related to vascular access devices, maintenance, dressing changes, and midline removal. No names, signatures, dates, or competency checks are listed on this document. There is no indication if or when this information was provided to RN O. The facility did not provide Surveyor with any documentation of competency checks regarding care of a resident with a midline for RN O. The facility provided Surveyor with an additional 17 Licensed Nurse Competency documents with the same notation under the section titled, Medication Management, there are many topics including one titled IV Therapy. Of these 17 documents, 14 had only the month and day documented, with no year. One additional Education/Training sheet was provided to Surveyor with 6 RNs, the DON (Director of Nursing), and one LPN listed that is dated 8/1/24. The IV Therapy policy is attached that is described above. However, the Midline Catheter Flushing-Lock-Removal policy is not. On 7/7/24 at 10:10 AM, Surveyor interviewed LPN N. Surveyor asked LPN N what her responsibilities were for the care of a resident with a midline. LPN N stated she flushes the midline, observes and monitors for signs of infection and pain, and makes sure everything is intact. Surveyor asked LPN N if she does dressing changes. LPN N stated, no, only the RNs do dressing changes. Surveyor asked LPN N what she would do if she noticed anything abnormal with the midline. LPN N stated she would call for another LPN/RN immediately. Surveyor asked what LPN N would do if she noticed there was bleeding, redness, or swelling at the site. LPN N stated, notify the nurse manager as soon as possible and notify the physician. Surveyor asked LPN N if she every completed a competency check for midlines. LPN N stated yes, I believe so, it was a long time ago. Surveyor asked LPN N how she knew how much fluid to flush into the midline. LPN N stated she would check the order. Surveyor asked LPN N what she looks for as she flushes a midline. LPN N stated to make sure it's flushing, if it's not blocked, and that the cap is on securely. Surveyor asked what LPN N would do if she noticed the midline was leaking. LPN N stated she would call the Nurse Practitioner, get the nurse manager to get the dressing off and check the line. Surveyor asked LPN N how she would know how long the line should be. LPN N stated the line should be measured with some documentation of how long it's supposed to be. On 11/7/24 at 10:13 AM, Surveyor interviewed RN BB. Surveyor asked RN BB how she cares for a resident with a midline. RN BB stated she monitors the site and line for signs and symptoms of infection, keeps the site clean, conducts sterile dressing changes, and makes sure the lines and dressing stay in place. Surveyor asked RN BB how she knows when the midline needs to be flushed. RN BB stated she flushed the line before and after medications, and once a shift with a heparin lock. Surveyor asked RN BB how she conducts dressing changes. RN BB stated that this is a sterile process, so sterile gloves and masks need to be worn, the site should be cleaned, and measurements should be made of the line. Surveyor asked RN BB how she knows when to do dressing changes. RN BB stated by physician order. Surveyor asked RN BB how she knows when to remove the midline. RN BB stated by physician order. Surveyor asked what RN BB would do if she found that the midline was leaking. RN BB stated she would contact the Nurse Practitioner and [Company Name] if the midline needs to be replaced. Surveyor asked RN BB if she has ever had a competency check related specifically to midlines. RN BB stated yes. Surveyor asked RN BB, who was working on R29's unit at the time of interview, if she recalled the incident with R29's midline. RN BB stated she does, and that she took care of the midline during the week on the day shift and did not notice any issues with the midline. Surveyor asked RN BB if she recalled the measurements for R29's midline, as they were not documented. RN BB stated she does not recall, but the measurements should be charted and believes this midline had the measurement markings directly on the midline. Surveyor asked RN BB how she delegates care of midlines to LPNs. RN BB stated she does not delegate this task and prefers to care for her resident's midlines herself. On 11/7/24 at 10:31 AM, Surveyor interviewed LPN F. Surveyor asked LPN F what she can do to care for a midline. LPN F stated she can't do anything with it unless they have a grenade (small ball of medication that is attached to the midline that self-administers medication). Surveyor asked LPN F if she can flush midlines. LPN F stated that she can. Surveyor asked LPN F how she knows when she's supposed to flush the line. LPN F stated she would check the order in the medication administration record. Surveyor asked LPN F how dressing changes are completed. LPN F stated that RNs do dressing changes. Surveyor asked LPN F what she would do if she noticed something different with the midline. LPN F stated she would get the RN as soon as possible to observe the site. Surveyor asked LPN F if she received any education from the facility on IVs. LPN F stated she received training on grenades. LPN F also stated they showed her how to flush and hook up the grenade with a return demonstration. LPN F stated that she has been agency staff at this facility for two years and prior to that was regular staff. LPN F estimates her last IV training to be around four years ago and said that she has not received additional training since coming back as agency staff around two years ago. Surveyor asked LPN F what she would do if she attempted to flush a line and met resistance. LPN F stated she would talk to the RN about it. On 11/7/24 at 2:50 PM, Surveyor interviewed LPN E. Surveyor asked LPN E what she does to care for midlines. LPN E stated she can't change dressings, but she can flush them and start IV medication. LPN E noted she is in school to become an RN and has documentation to show she has completed an IV therapy class in school. Surveyor asked LPN E what she checks for when caring for a resident with a midline. LPN E stated she would look for signs and symptoms of infection and that the dressing is intact. LPN E stated she would clean the port or remove the cap cover to use the line. LPN E also notes she has seen one with clamps but it's been months since she had a resident with a midline. Surveyor asked LPN E what she would do if she met resistance while trying to flush a midline. LPN E stated she would replace the cap and get a nurse manager. Surveyor asked LPN E if she would remove the midline. LPN E stated no, she is not allowed to do that and there should be an order to remove the midline. Surveyor asked LPN E if she has completed a competency check for caring for residents with a midline. LPN E stated she cannot remember, she believes it is on the [Name] outside training and that they have come around with the steps before. Surveyor asked what LPN E would do if the midline was broken or falls apart. LPN E stated she would go get the nurse manager. Surveyor asked LPN E what she would do if the midline is leaking. LPN E stated she would stop flushing and get the nurse manager as the line is probably dislodged. Surveyor asked LPN E how she knows what to flush and how much. LPN E stated she would check the order in the electronic medical record. Surveyor asked LPN E if she had ever attended a skills fair. LPN E stated no. On 11/7/24 at 2:54 PM, Surveyor interviewed LPN LL. Surveyor asked what LPN LL does to care for midlines. LPN LL stated he does not care for them, he has the RN care for them. Surveyor asked LPN LL if he monitors anything with the midline. LPN LL stated he monitors the site and dressing and if something doesn't look right he tells the RN and informs DON B. On 11/7/24 at 4:24 PM, Surveyor interviewed DON B. Surveyor asked DON B to describe the issue that occurred in July with R29's midline. DON B stated, we had an order to remove the midline, RN O removed it and realized it wasn't intact. R29 was sent out to the hospital and eventually transferred to a second hospital. R29 returned to the facility with the catheter still in her arm due to second outside hospital being unable to remove it. The facility then made referrals to get R29 the care she needed. Surveyor asked DON B if RN O had received a telephone or verbal order to remove the midline and if the order should have been transcribed into the electronic medical record. DON B stated she would have expected it to be transcribed. DON B also added that she would expect some sort of progress note or change of condition note regarding this event. Surveyor asked DON B if a midline could ever be removed without an order. DON B stated no. Surveyor asked DON B if she was aware there was no order in the electronic medical record to remove the midline. DON B stated no. Surveyor asked DON B what she would expect staff to monitor for in residents who come to the facility with a midline in place. DON B indicated she would expect staff to monitor the insertion site for infection, redness, swelling, pain, and when the line is removed to check to make sure the catheter is intact. Surveyor asked DON B if she would expect staff to notify a provider if a midline was leaking. DON B stated yes. Surveyor asked DON B what she would expect to happen after LPN P notified RN O of the midline not flushing. DON B indicated she would expect an LPN to get an RN to assess the line immediately and to notify the Nurse Practitioner right away. Surveyor asked DON B how often she expects dressing changes to be conducted. DON B stated weekly. Surveyor asked DON B where Surveyor could find that documented. DON B stated, in the TAR (Treatment Administration Record). DON B added that this comes in as an order and an RN is expected to add this into the TA[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change of condition for 1 of 3 sampled residents (R1). On [DATE], R1 experienced a change in condition exhibiting as shortness of breath and critically low oxygenation. The facility failed to recognize the change of condition as a medical emergency, complete a comprehensive cardiorespiratory data collection, and consult with the RN which resulted in a delay of treatment. LPN E's (Licensed Practical Nurse) failure to recognize a change of condition, complete a comprehensive cardiorespiratory data collection, and consult with the RN resulted in a delay of treatment and created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. On [DATE] at 2:15 PM, NHA A (Nursing Home Administrator) was informed of the IJ. The IJ was removed on [DATE] when the facility recognized the IJ and implemented an immediate action plan. The IJ was corrected on [DATE]. This is evidenced by: The facility policy titled Notification of Changes Policy dated [DATE], states in part: Policy: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate .Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative , and the resident's physician, to ensure best outcomes of care for the resident DEFINITIONS Significant change in status - deterioration in health, mental or psychosocial status in life threatening conditions or clinical complications Significant alteration in treatment - A need to alter treatment significantly. A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. OBJECTIVE OF THE NOTIFICATION OF CHANGE POLICY The objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician and delegated Non-Physician Practitioner and immediate notification to the resident and/or the resident representative when there is a change in the resident's condition, or an accident that may require physician intervention. The intent of the policy is to provide appropriate and timely information about changes relevant to the resident's condition .to the parties who will make decisions about care, treatment, and preferences to address the changes. OVERVIEW OF COMPONENTS OF THE POLICY 1. Requirements for notification of resident, the resident representative, and their physician . 2) A significant change in the resident's physical, mental, or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications . Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments . PROCEDURE FOR NOTIFICATION OF CHANGES FOR RESIDENT PURPOSE The facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences. PROCEDURE 1. The nurse will immediately notify the resident, resident's physician, and the resident representative(s) for the following (list is not all inclusive): . b. A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication. c. A need to alter treatment significantly a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. d. A decision to transfer or discharge the resident from the facility . 3. Document the notification and record any new orders in the resident's medical record . 7. Communicate the changes to the rest of the care team and inform the supervisor . According to Wisconsin Statutes N 6.04 Standards of practice for licensed practical nurses. (1) Performance of acts in basic patient situations. In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care assignments which the L.P.N. is competent to perform. (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. (2) Performance of acts in complex patient situations. In the performance of acts in complex patient situations the L.P.N. shall do all of the following: (a) Meet standards under sub. (1) under the general supervision of an R.N., physician, podiatrist, dentist or optometrist. (b) Perform delegated acts beyond basic nursing care under the direct supervision of an R.N. or provider. An L.P.N. shall, upon request of the board, provide documentation of his or her nursing education, training or experience which prepares the L.P.N. to competently perform these assignments. R1 was admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with (acute) exacerbation (COPD) and dependence on supplemental oxygen. R1's Minimum Data Set (MDS) with an assessment date of [DATE] includes the following: Brief Interview of Mental Status (BIMS) assessment score of 14 indicating R1 is cognitively intact. Section J1100 C. Shortness of breath or trouble breathing when lying flat was marked. J1400 Prognosis. Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? 'No' was marked. O0110 Special Treatments, Procedures, and Programs C1. Oxygen therapy while a resident was marked. R1's physician orders included the following: DNR (Do Not Resuscitate) start date [DATE]. Q4 (every 4 hours) vital signs every 4 hours start date [DATE]. Continuous Oxygen via NC (Nasal Cannula) 3L (3 Liters) every shift start date [DATE]. Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML) 0.083%v (Albuterol Sulfate) 1 vial inhale orally via nebulizer three times a day for COPD exacerbation start date [DATE]. Mometasone Furo-Formoterol Fum Inhalation Aerosol 200-5 MCG/ACT 2 puff inhale orally at bedtime for COPD start date [DATE]. Mometasone Furo-Formoterol Fum Inhalation Aerosol 200-5 MCG/ACT 2 puff inhale orally one time a day for COPD start date [DATE]. Spiriva HandiHaler Inhalation Capsule 18MCG 1 puff inhale orally one time a day for COPD rinse mouth after use start date [DATE] R1's comprehensive care plan Alteration in Respiratory Status Due to Chronic Obstructive Pulmonary Disease, Chronic Hypoxic Respiratory failure. Oxygen Dependent. Dated [DATE] has goals of Patient will have adequate gas exchange as evidenced by no adventitious breath sounds, absence of respiratory distress, and absence of shortness of breath. Patient will remain free of exacerbation of COPD. Interventions include Observe labs, response to medication and treatments. Administer oxygen as needed per Physician order. Monitory oxygen saturations on room and and/or oxygen. Monitor oxygen flow rate and response. Elevate HOB (Head of Bed) to alleviate shortness of breath. Monitory cough and effectiveness of inhaler/nebulizer. Notify practitioner if symptoms worsen or do not resolve. R1's Progress Notes written by LPN E (Licensed Practical Nurse) include the following: [DATE] 10:56 (AM) Note Text: At 0725 (7:25AM) res (R1) was on call light requesting a boost due to SOB (Shortness of Breath) because she was to [sic] low. Writer went to get an aide to assist, and res was repositioned, and HOB (Head of Bed) was raised. After that writer went to get res nebulizer (a device for producing a fine spray of liquid for inhaling a medication) meds (medication) and ran that with mask (a face mask used to administer medication via a nebulizer). And writer also gave the res an inhaler. Res breathing was labored. Checked res POX (Pulse Oximetry, a noninvasive method for monitoring blood oxygen saturation) and it was 62% on oxygen at 3L (Liters) via NC (Nasal Cannula), writer increased oxygen to 4L. Writer came back in a little while and rechecked res POX and it had gone up to 69% but writer had CNA (Certified Nursing Assistant) get res a mask (a face mask to administer oxygen) and it was applied to the res instead of the NC. Res was responsive at that time. Writer rechecked POX and it was at 72%. Res was responsive at that time. Writer went back soon after this to recheck res POX and at that time res noted to have her eyes rolling up and not responding to verbal but did have a slight response to touch. POX was down to 54% on mask so writer went and called EMS (Emergency Medical Services) to come for resident. Writer went back into res room and stayed there with res until EMS arrived. Res was not really responsive then and was pale in color and had labored breathing but when writer went and held res hand res did respond to it. According to Lippincott Nursing 2024 King, [NAME] E. RN, C, ACNP, ANP, PhD. How do I choose a supplemental oxygen delivery device? Nursing 33(12):p 32, [DATE] states in part; perform a more complete physical assessment. Besides the patients SPO2 (blood oxygen level), note the respiratory rate, quality of breath sounds, use of intercostal muscle (muscles around ribs, if noting intercostal muscle use the patient is working hard to breath), presence of mottling (bluish color of skin), heart rate and any cardiac arrhythmias. The nasal canula is most appropriate for patients experincing minimal respiratory distress. The flow rates rate from 1 to 6 liters. Like the nasal canula the face mask mixes oygen with room air but can provide higher oxygen concentration and higher flow rates (5 to 10 Liters). To prevent carbon dioxide accumulating in the mask, maintain an oxygen flow rate of at least 5 liters/minute. Of note, despite R1's significant respiratory history and R1's presentation LPN E did not listen to R1's lungs or complete a full respiratory review of R1. At no time did LPN E consult with a RN regarding R1; instead LPN E left R1's room despite R1 showing increased respiratory distress as evidenced by low O2 sats and labored breathing. Additionally, LPN E chose to use an oxygen mask with a low oxygen delivery of 4 liters per mask which would have increased the carbon dioxide accumalation in the mask making breathing more difficult for R1 and furthering R1's respiratory distress. EMS report dated [DATE] includes the following information: Clinical Impression: Primary Impression: Acute Respiratory Distress. Onset Time: 07:00 (AM) [DATE]. Chief Complaint: Respiratory distress. Duration: 2 hours. Signs & Symptoms: Acute respiratory distress (Primary), Slowness and poor responsiveness. Initial Patient Acuity: Critical (Red) Vital Signs: Time 09:08 (AM) BP (Blood pressure) Blank. Pulse Blank. RR (Respiratory Rate) 10 R. SPO2 (Oxygen Saturation) 70 Rm. (on room air) Time 09:13 (AM) BP 60/42. Pulse 111. RR 12 R. SPO2 93 Ox. Flow Chart: Time: 09:09 (AM). Treatment: Oxygen. Description: Device: Non-Re-breather Mask (NRB); Flow Rate; 15 lpm; Patient Response: Improved; Successful; Complications: None; Medical Control: Protocol (Standing Order) Time 09:13 (AM). Treatment: Oxygen. Description: Device: Bag Valve Mask (BVM); Flow Rate: 15 lpm; Patient Response: Improved; Successful; Complication: None; Medical Control: Protocol (Standing Order) Assessments Time 09:08 (AM) Mental Status - Slowness and poor responsiveness. Skin - Cold, Cyanotic (bluish or purplish discoloration due to deficient oxygenation). Eyes - Left: Non-Reactive, right: non-reactive. Extremities: Cyanotic extremities. Narrative: [Ambulance Number] was dispatched to a nursing home for difficulty breathing. [Ambulance Number] responded emergent and arrived on scene without incident. On arrival EMS crew was met at the front door by facility staff and escorted to pt's (R1) room. On contact pt was [age] GCS 7 (Glasgow Coma Scale indicating severe traumatic brain injury requiring immediate emergency care) laying upright in bed with an oxy (oxygen) mask on. Pt had shallow respirations and was cyanotic in the extremities. Pt's eyes were moving on initial contact. Nursing home staff state she has a history of pulmonary failure and started to have acute difficulty breathing around 0700 (7:00AM) this morning, which has not improved with their treatments of oxygen and a nebulizer. Nursing home staff state that her initial spO2 was 60% on a 2 LPM NC (liters per minute/via nasal canula), spO2 at time of EMS contact 71% on oxy mask @6 LPM. Nursing home state they obtained an automated blood pressure of 81/42 prior to EMS arrival. EMS unable to obtain with monitor, radial pulse was weak. EMS was presented with a valid DNR for the pt, as well as med list indicating the pt was on blood thinners. Unable to obtain stroke scale due to pt's GCS. Pt slide sheet transferred over to stretcher and a NRB was applied @15 LPM. Pt moved via stretcher to [Ambulance Number]. In [Ambulance Number] a 4-lead was applied showing a tachy sinus arrhythmia (an irregular and faster than normal heart rate). SpO2 remained at 69% on NRB (Non-rebreather/face mask), BVM (Bag Valve Mask-device used to deliver ventilation to patient) ventilation started due to shallow respirations, raising the spO2 to 93%. Pt began to increase ventilatory effort following BVM, however it was noted that her eyes were now fixed. [Ambulance Number] started emergent transport to hospital. Enroute BVM was continued with spO2 remaining above 90%. BP obtained enroute was 60/42. [Ambulance Number] arrived at [ER Name] without incident and pt was moved via stretcher to ER room [ROOM NUMBER] where she was slide sheet transferred to bed. Care, report, and DNR (Do Not Resuscitate) paperwork transferred to RN. [Ambulance Number] cleared [ER name] following decon (decontamination). Level of Service: Advanced Life Support Incident Times: Call Received 09:01:04 Dispatched 09:01:13 En Route 09:01:44 On Scene 09:05:29 At Patient 09:07:00 Depart Scene 09:14:16 At Destination (Hospital ER) 09:15:45 Pt. Transferred 09:17:16 [DATE] 10:52 (AM) Note Text: Res left via EMS around 0914 (9:14AM). ER (Emergency Room) updated on res going over there for evaluation at 0916 (9:16AM) and son [Name] updated that res was going to the ER due to low oxygen sats (Oxygen Saturation) at 0918 (9:18AM). [Name] NP (Nurse Practitioner) consulted regarding res low POX and low BP (Blood Pressure) and high pulse, send to ER. Hospital Emergency Department report dated [DATE] includes the following: Date of service [DATE]. Chief complaint: Difficulty breathing. Unable to obtain history r/t (related to): Other - Patient nonverbal due to critical nature presentation. Comments: .presents to the emergency room by ambulance for evaluation of respiratory distress which did not respond to a breathing treatment at the nursing home . When she was brought into the emergency department the patient was being bag (manual ventilation) and she was having agonal respirations (a distinct and abnormal pattern of breathing) she did have a palpable pulse, but she did not have any other signs of life she was not responding to needlestick or questioning . General Appearance: other - Patient is not responding to stimulation or verbal communication . Eyes: Bilateral: Other - The right pupil is blown left pupil is 6 mm but not responding Respiratory: Other - Decreased air movement only noted with bagging. Neuro/Psych: Other - On arrival patient had a blown pupil on the right. She was not responding to verbal communication she was not responding to tactile stimulation or needlestick. Medical Decision Making: Summary of care: Patient presents with agonal respirations and appeared to be at end of life. She is a DNR. I spoke to the son who has power of attorney and comfort care measures were started. Patient was given intravenous morphine Zofran and lorazepam. Shortly after arrival patient lost all signs of life. She had no palpable pulse no cardiac sounds and no respiratory effort. No neurologic function. Clinical course as noted above after speaking with the son since she is a DNR comfort measures were started the patient expired at 9:55 a.m. [DATE] 11:14 (AM) Note Text: At 1000 (10:00AM) received call from [Name] ER that res was pronounced dead at 0955 (9:55AM). [Name of practitioner] NP was consulted regarding res pronounced dead after phone call from ER. [DATE] 11:16 (AM) Note Text: [Name] DON was updated at 1045 (10:45AM) regarding res passing at [Name] ER. On [DATE] at 9:49 AM, Surveyor interviewed PO D (Police Officer - Detective). PO D indicated the facility contacted the police and reported the incident as possible neglect due to the delay in treatment. PO D indicated she spoke with the medical examiner in charge of R1's case. PO D indicated there was an autopsy which revealed preliminary cause of death as COPD, emphysema, and lung disease. PO D and medical examiner discussed the case, and it was said that being deprived of adequate oxygenation might be a contributing factor for the cause of death. On [DATE] at 10:26 AM, Surveyor interviewed NP C (Nurse Practitioner). NP C indicated she was not made aware of R1's change in condition until after R1 was sent to the ER which was almost 2 hours after the change in condition started. NP C stated she had ordered vital signs every four hours for R1 because of R1's condition. NP C indicated R1 had no reserve due to end stage COPD. NP C indicated the first oxygen saturation of 62% was a critical value and R1 should have been sent to the ER immediately. NP C indicated she does not believe the situation was handled correctly. NP C indicated staff should have called 911 then attempted other interventions like the inhaler or nebulizer as they waited for EMS to arrive. NP C agreed being deprived of adequate oxygen for that long could have been a contributing factor to R1's death. NP C indicated it is her expectation that any critical values in vital signs need an immediate phone call to the provider. On [DATE] at 4:06 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated R1 had a hospice consult on [DATE] but declined hospice services. DON B indicated she was notified of R1's death on [DATE]. DON B indicated on [DATE], LPN E did not give details of what happened that lead to R1 being sent to the hospital and passing. On [DATE], after reviewing LPN E's documentation, DON B suspended LPN E and started an investigation. DON B indicated she would have expected LPN E to call the NP and send R1 to the hospital for a pulse oximetry reading of 62%. DON B indicated LPN E did delay treatment for R1. On [DATE] at 8:40 AM, Surveyor interviewed LPN E. LPN E indicated the following: At 7:30 AM R1 had her light on and needed a boost up in bed because she was short of breath. LPN E left the room to get a CNA on a different hallway. They returned and boosted R1 up in bed. After they boosted R1, LPN E went to her cart to get a nebulizer treatment that took about 15 minutes to run. LPN E also grabbed an inhaler for R1 and brought in a pulse oximeter. LPN E checked R1's O2 sats (oxygen saturation) and it was 62% on 3L. LPN E turned the oxygen up to 4L at that time. LPN E left the room and came back a little later and rechecked R1's O2 sats. It was 69%. LPN E then had a CNA get an oxygen mask and change it out with the nasal cannula. LPN E then came back a little later and R1's O2 sats was 72%. LPN E left R1's room and returned to her medication cart. LPN E prepared another resident's medications and went to administer that resident's medications to them. Then LPN E went back to R1 to recheck O2 sats which was now at 52%. LPN E ran out of the room and called 911. LPN E returned to R1's room and waited for EMS to arrive. Upon EMS arrival, LPN E gave EMS report then left the room. LPN E then escorted EMS out of the building. LPN E then called ER to give them report on R1 being sent there and called R1's son. Surveyor asked LPN E when she first took an O2 sats reading for R1. LPN E indicated she checked R1's O2 sats for the first time after boosting R1 and administering the nebulizer and inhaler. LPN E indicated R1 was a DNR and R1's O2 sats were going up slowly. LPN E indicated in hindsight LPN E would have done things way different. LPN E indicated she would have called 911 after the first O2 reading of 62%. On [DATE] at approximately 7:30 AM, R1 complained of shortness of breath. R1's O2 sats were not obtained for approximately 20 minutes. R1's O2 sats at that time was critically low at 62% and remained low. The facility did not notify the provider. The facility called 911 at 9:01AM, approximately 1.5 hours after the facility noted the change in condition. R1 expired at 9:55AM. The facility's failure to recognize a change of condition complete a comprehensive cardiorespiratory data collection and consult with the RN resulted in a delay of treatment creating a finding and immediately notify the physician created a finding of IJ which was removed, on [DATE], when the facility implemented the following action plan: Investigation initiated. Police notified. Nurse suspended. Chart review completed. Hospital notes reviewed. Staff statements obtained. Like resident statements obtained Skin assessments completed on residents with BIMS of 12 or less. Audit completed on all change in conditions within the last week to ensure RN (Registered Nurse) assessment completed and Nurse Practitioner was updated timely. Audit completed on oxygen use orders. Audit completed on all vital signs to determine if there were any missed vital signs or abnormal vital signs. Review of all nursing competencies Review of crash carts Audit of Code status Audits daily x (for) 30 days for change in condition, appropriate assessments, vital signs completed, any new orders completed, place d on 24-hour board, and continued follow up. Respiratory assessments reviewed or completed on residents with Respiratory diagnosis. [NAME] Clinical Consulting educated the QAPI (Quality Assurance and Performance Improvement) committee on notifications/investigations that must begin off-hours for any death or unusual event. Education completed for all licensed staff and CNA's. Recognition of change in condition with post test O2 orders with post test Following MD orders and MD notification MD and RN notification Vital signs and Baseline vital signs with post test Education completed for all staff. Change in condition. Reporting to nursing any changes Abuse, Neglect, Misappropriation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident's right to be free from verbal/mental abuse by a Certified Nursing Assistant (CNA). This affected 1 of 4 residents (R1) reviewed for abuse. R1 had a verbal altercation with CNA C (Certified Nursing Assistant) which led CNA C to become angry and perseverate on the altercation. CNA C then wrote a letter to R1 telling him that she was going to kill him. The facility's failure to keep residents safe from verbal/mental abuse created a finding of Immediate Jeopardy that began on 5/26/24. The Administrator was informed of Immediate Jeopardy on 6/11/24 at 1:26 PM. The immediate jeopardy was removed and corrected on 5/27/24. This is being cited as past noncompliance. Evidenced by: The facility's policy titled Abuse, Neglect, and Exploitation dated 10/1/22, states in part It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: .Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . R1 was admitted to the facility on [DATE] with diagnoses that include encephalopathy (a broad term for any brain disease that alters the brain function or structure), type 2 diabetes mellitus, hallucinations, and congestive heart failure (CHF; a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). R1's most recent Minimum Data Set (MDS) dated [DATE] states that R1 had a Brief Interview of Mental Status (BIMS) of 10 out of 15 indicating that R1 has moderate cognitive impairment. R1's MDS also indicates that R1 is dependent on staff for transfers, toileting, and dressing. R1 is wheelchair bound. On 5/26/24, R1 had a verbal altercation with CNA C. R1 had yelled at CNA C for not closing his door. This led to CNA C becoming quite upset and repeatedly telling her co-workers about the incident. On 5/27/24, R1 found a note in his room that stated: [R1] don't f***ing swear at me about closing the door and if you ever yell and swear at me again I will f***ing kill you due to man like you who is mental retard due to causing drama for no reason and don't take order from man like you. I don't like you and I hope you drop dead someday. {sic} R1 showed the note to a CNA, who reported the note to the Licensed Practical Nurse (LPN), who then gave the note to the Director of Nursing (DON). On 5/27/24, the facility began an investigation. Witness statements are as follows: CNA D writes in part, On Sunday, May 26th, a CNA, [CNA C] approached me, very upset, stating that R1 cussed her out for not shutting his door. These are things that were said to me by CNA C throughout remainder of out PM (evening) shift. CNA C repeatedly (emphasis intended) told me the story. She said that he has ruined her happiness of the day and that she doesn't deserve it because she didn't do anything wrong. She repeatedly told me how angry she was, literally over and over. She said, no one will talk to me like that and that as long as she doesn't hit or shoot anyone, she will be ok. She said she was going to stand up for herself .I tried de-escalating her thoughts numerous times. I told her that I get cussed at sometimes too, and that it happens to everyone. She did not want to hear any of that. I could sense the anger was brewing .I said that we cannot allow ourselves to become reactive to behaviors. She then went back and literally repeated the entire story .Upon clock out time, downstairs by the time clock, CNA C was still carrying on about how R1 had ruined her night, the whole story, literally all over again .The nurse and I discussed her behaviors, and I clocked out and went to my car. Statement from LPN E was obtained by DON B via a telephone call is as follows, On Sunday night 5/6/24 CNA C got very angry and upset about R1 being mean and swearing at her. CNA C asked LPN E if she doesn't hit or swear at other residents, was there anything else she shouldn't do. LPN E told CNA C even the tone of voice can be a problem and not okay. CNA C got upset with LPN E. CNA C then went to CNA D and was talking about how R1 was swearing at her. Statement from CNA F states, On 5/26/24 when picking up supper trays, CNA C came to the nurse's station stating she didn't understand why R1 swore at her. He never swore at me before. He was swearing because I didn't close his door. She continued on about him swearing at her and was telling other staff member how he was swearing at her. She was still talking about when I left my shift at 8 PM. It is important to note that Surveyor called and left messages for CNA D and LPN E and has not received return calls. Statement from CNA G states in part, .I was walking through the hallway and resident called me over to help him and turn off the A/C (air conditioner), while I was leaving the room, he asked me who the manager was of this place and told me that someone hates me here he was in his wheelchair and pulled out the note from his dresser. So, I asked the [sic] from across the hall to help me and I handed her the note. Statement from LPN H states in part, [CNA] alerted writer that R1 had a letter in his room that was threatening resident. Writer went to resident's room and reported the letter to DON B immediately. Writer asked resident when he noticed the letter, resident stated after lunch, but it could have been before lunch. Resident stated the letter was in his chair on top of clothes next to his sink .Writer asked resident if there was any staff who he may have yelled at, or any staff who seemed upset, resident stated no, I yell at everyone to close my door and they always leave it open. Resident asked if there is any staff he does not get along with, resident stated no. Resident asked if there is any staff he does not like? Resident stated no. Resident stated, Surprisingly this weekend no one's been an issue. Resident asked if he feels scared for his safety. Resident stated No, I wish they would come see me, I have lived in scarier places in my life. It should be noted that R1 has a BIMS of 10, an activated healthcare power of attorney, and a diagnosis including encephalopathy. R1's response to the threatening letter is incongruent to how a reasonable person would respond to receiving a letter in their home that threatens to kill them and humiliates them, especially if the individual were dependent on others to provide daily care for them. A reasonable person would have extreme fear, anxiety, and feel humiliated by the threat and derogatory language used in the letter. Statement from CNA C on 5/27/24 states: 1. Not in my computer 2. Walked in hallway and went to his room to check on him and he was okay in bed. I turn around and I saw the letter on the chair and that's when I touched the paper, when I did however glance a little bit to know the first sentence was, I got scared and walk away from his room. 3. Later on, the PM shift is when other staff saw the letter on the chair and took it with them, to the nurse station to figure out who did the typing the letter about [R1] death wish. I did touch it again to see the whole story about the letter, but they saw it first in the nurse station first before I touch it again. 4. I never did type and print the letter. {sic} On 5/28/24, NHA A (Nursing Home Administrator) called the local police department. PO I (Police Officer) responded to the call. PO I's report states that he spoke with NHA A who suspected that CNA C wrote the letter, but at this time was unable to prove it and that CNA C quit when she was being questioned about leaving the note. PO I spoke with R1 who stated that he did not want a complaint and did not feel scared. R1 just wanted the information documented. NHA A reported that CNA C would not be hired back at the facility and currently lives in [city name]. On 5/29/24, NHA A requested that CNA C bring in her personal laptop so they could search it for any indication that she wrote the letter. CNA C complied and brought the computer to the facility. The Administrative Assistant looked through the computer and it appeared that it had been dry erased. Per the facility's investigation summary, the Administrative Assistant spoke with CNA C again, and eventually CNA C confessed to writing the letter. CNA C reported to the facility administration that she was having mental health issues. Statement from CNA C on 5/29/24 states: + Went to library in [city name] for typing the letter to make the point to him about him yelling at me about closing door and I got carry away with it and I'm very, very sorry about the whole situation about the incident. + I don't hate him, and we never argue either. His did yell at me by accident due to him having bad day. + I will never do that ever again. This is only incident that I dealt with only. + I wish nothing would happen to him at all. I'm so glad he is safe and sound. I don't think he is mean person. {sic} On 6/10/24 at 9:59 AM, Surveyor interviewed R1. Surveyor asked R1 about the letter he received, R1 reported that the letter said, I want to kill you and You should die. Surveyor asked R1 what he did once he found the letter, R1 stated that he gave it to someone in charge. R1 also reported to Surveyor that the police came and asked him some questions. Surveyor asked R1 how receiving the letter made him feel, R1 stated, I didn't give a s**t. I was a little worried because I'm in a wheelchair, if they wanted to kill me, they probably could. R1 reported to Surveyor that he feels safe and is not fearful of staff. On 6/10/24 at 1:28 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if CNA C was terminated, NHA A stated that CNA C was suspended and required to seek treatment for her mental health issues prior to returning to work. On 6/10/24 at 3:36 PM, Surveyor interviewed PO I. Surveyor asked PO I about his investigation regarding the letter that R1 had received, PO I stated that he came to the facility and spoke with R1 and NHA A and at that point there was no proof that CNA C had written the letter, therefore there was nothing else he could do. Surveyor asked PO I what R1's response was to the letter, PO I stated that R1 reported that he was not scared, was not in fear, and was not intimidated by the letter. PO I reported that NHA A updated him that CNA C had confessed to writing the letter, but neither R1 nor the facility wanted to press charges. Surveyor asked PO I if a threat, like the one R1 had received, would be criminal in nature, PO I stated, with a victim, yes it would be. On 6/13/24 at 1:05 PM, Surveyor interviewed LPN H. Surveyor asked LPN H to recall the day she was made aware of the letter, LPN H stated that she was at the nurse's station and a CNA asked her if she had heard about the letter. LPN H stated that she had not and accompanied the CNA to R1's room, read the letter, and then immediately called DON B. LPN H stated that she questioned R1 about the note, if he felt safe, and if he knew where the note came from. Surveyor asked LPN H what time she was made aware of the note, LPN H stated that it was around 8:00 PM. Surveyor asked LPN H if she had worked with CNA C in the past, LPN H stated yes. Surveyor asked LPN H if CNA C had displayed behaviors in the past, LPN H stated never, and she was shocked when she found out that CNA C had written the letter. R1 is dependent on staff for all care. R1 received a letter threatening to kill him and used derogatory language toward R1. A reasonable person would have extreme fear and anxiety if they received a letter in their home stating a subject wanted to kill them and would be humiliated with the use of derogatory language. The facility's failure to prevent and protect residents from verbal/mental abuse created a reasonable likelihood for serious harm to occur and a finding of Immediate Jeopardy. The facility removed and corrected the immediate jeopardy on 5/27/24 when it completed the following: 1. Initiated immediate investigation. 2. Trauma assessment completed for R1 3. PHQ9 (Depression screening) assessment for R1. 4. Completed a new BIMS for R1. 5. Abuse Policy education to all staff. 6. R1's care plan was updated. 7. Placed R1 on 15-minute checks. 8. R1 was placed on the 24- hour board to monitor psychosocial well-being. 9. Interviewed residents and staff regarding abuse. 10. Complete skin checks on residents who were not able to be interviewed. 11. Suspended alleged employee. 12. Education to all staff to immediately notify management if they have a concern regarding staff burnout.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 4 R3 was admitted to the facility on [DATE], and has diagnoses that include alcohol abuse, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury). R3's admission Minimum Data Set (MDS) Assessment, dated 11/20/23, shows that R3 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R3 is cognitively intact. R3's Smoking and Safety Assessment, dated 11/10/23, states, in part: AS_1. Smoking Safety Interaction 1. Smoking and Safety. 1.Supervision, designated smoking location, and smoking times are determined by facility policy. This evaluation will be utilized for the Resident's smoking care plan on admission and as indicated. 2. Which of the following products does the Resident use? Tobacco 3. Does the Resident display any of the following? Follows the facility's policy on location and time of smoking . AS_2. Care Planning 1. Care Planning 1. Smoking Care Planning- . Note: Nothing is checked under Smoking Care Planning, nor does this assessment indicate whether R3 is safe to smoke unsupervised or with supervision. R3's Care Plan initiated 11/10/23 does not include R3 smokes or smoking safety measures. R3's Certified Nursing Assistant (CNA) card, as of 2/21/24, does not include R3 smokes or smoking safety measures. On 2/21/24 at 2:35 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated smoking assessments are completed by the floor nurse admitting the resident. The assessment then gets entered into PCC (point click care) and then DON B or the MDS nurse enters the smoking care plan into the resident's medical record. Surveyor asked DON B for a resident who smokes would you expect a care plan in place regarding smoking. DON B indicated yes. Surveyor asked DON B for R3 is he care planned for smoking. DON B looked up R3's care plan and indicated no. Surveyor asked DON B if R3 should be care planned for smoking and DON B indicated yes. Example 5: R3 was admitted to the facility on [DATE], and has diagnoses that include alcohol abuse, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury). R3's admission Minimum Data Set (MDS) Assessment, dated 11/20/23, shows that R3 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R3 is cognitively intact. R3's Care Plan initiated 12/15/23, states, in part: . Focus: Per care team, resident has a history of using marijuana and alcohol during stays at other facilities. Resident has had alcohol here per staff and tested positive for THC, and Benzos without prescription. Would not state how this occurred. Per care team, resident has history of aggression towards staff at previous placements. Signed Behavior Contract 2/2024 Date Initiated: 12/15/23. Goal: R3 will remain safe and not pose a safety risk to others during stay at (facility name). Date Initiated: 12/15/23 Revision on: 1/10/24 Target Date: 5/16/24. Interventions/Tasks: -Attempt interventions before behaviors begin. Date Initiated: 12/15/23 Revision on: 12/15/23. -Give me my medications as my doctor has ordered. Date Initiated: 12/15/23. -Make sure I am not in pain or uncomfortable. Date Initiated: 12/15/23. -Please refer me to my psychologist/psychiatrist as needed. Date Initiated: 12/15/23 . R3's NP progress note dated 1/26/24, 4:15 AM, states, in part: . Patient appeared dazed, confused, and did not make total sense. Did call nurse into the room who also felt patient was slightly off baseline. No reports of fever, chills, nausea, vomiting, diarrhea, constipation, shortness breath, chest pain. Patient eats meals fairly well but reports he does not sleep well. Reviewed facility EHR (Electronic Health Record), medication list, discussed care with facility staff. They will continue to monitor and update provider for any acute changes or concerns ***Follow-up*** Blood alcohol/drug screen . R3's progress note dated 1/27/24, at 7:15AM, states, Writer found Vape pen on Resident. NHA and DON notified. R3's Progress Note, dated 1/27/24, at 7:30 AM, states Urine sample obtained for drug screen. R3's Progress Note, dated 1/27/24, at 2:48 PM, states Lab results received positive for THC and Benzodiazepines. R3's Progress notes dated 1/27/24 through 2/20/24, when R3 discharged , there is no mention of any type of service offered to R3 for substance use. R3's Drug Screen, dated 1/27/24 shows THC- Positive and Benzodiazepines- Positive. On 2/21/24 at 11:57 AM, Surveyor interviewed SW D (Social Worker). SW D indicated services were not offered to R3. SW D indicated if she would have offered and R3 indicated wanting services SW D would not have known what to do or where to go with that. SW D indicated the facility could not provide transportation. SW D indicated she does not know the protocol if R3 did want services and in hindsight the facility did not fully address R3's SUD (substance use disorder). Example 6 R7 admitted to the facility on [DATE]. She has the following diagnoses: Major Depressive Disorder, Bipolar Disorder, Personal History of Other Mental and Behavioral Disorders, Generalized Anxiety Disorder, Sedative/Hypnotic or Anxiolytic Dependence, and substance abuse. R7's Hospital Discharge, dated 12/14/23, includes: . Diagnoses: substance abuse (CMP), history of heroin and cocaine- last use 12/5/19 . vaping use- daily . R7's Physician Ordersinclude, in part, Gabapentin for neuropathic pain, hydroxyzine for anxiety and itching, Lamotrigine for seizures, Lyrica/Pregabalin for pain (discontinued 1/16/24), Quetiapine Fumarate for Bipolar Disorder with psychotic features and Sertraline HCI for Depression. R7's Psych Consult, dated 1/19/24, includes: Patient is . being seen today for a psych follow up. She is observed sitting upright in her wheelchair in her room. She appears lethargic and asleep-she is slumped over in wheelchair with mouth hanging open. Writer said hello and knocked on door, patient seemed to startle. She is disoriented, does not know where she is or who writer is, despite having met multiple times. Patient presents with signs of opioid impairment: Psychomotor retardation, slurred speech with delayed response time. A tech and nurse reported to writer that the CNA who got patient up and out of bed this morning-saw a baggy of suboxone fall from her pocket. Per that CNA, patient retrieved the bag of films and put bag back in her pocket. This was reported to writer several hours later .Writer returned to patients room and asked if she has been using suboxone. Patient was immediately honest and said she was just trying to get rid of the pain. She says she has been taking 8-16mgs everyday/every other day for pain, and her best friend brought her a bunch. Writer asked for the remaining films she had left and she said she had none. Writer asked again and patient retrieved two 8mg sublingual films from her dresser drawer. She handed them to writer and asked, Can I still take them? Writer said no, as she did not prescribe this to the patient, writer is unsure where these came from and who the prescription even belongs to. Patient told writer she took 16mgs today. Writer informed patient that her Lyrica had been discontinued due to the dangerous interactions between Pregabalin and Buprenorphine. Writer explained the increased risk of CNS (Central Nervous System) depression/sedation when these two medications are combined. Writer also explained the risk of Buprenorphine withdrawals that she may experience based on how long and how much she has actually been taking. Patient verbalized her understanding of this and asked if she could get some kind of pain medication if she stopped using Buprenorphines that were not prescribed/provided by writer. Writer stated that pain management could be revisited again if she could provide 14 consecutive urine drug screens. Facility Visitor Log, indicates R7's friend visited on the following dates: 1/17/24, 1/21/24, 2/19/24. (It is important to note this visitor visited on the date of 1/21/24 and the next note by Nurse Practitioner with date of 1/22/24 where resident is observed to be impaired again.) R7's Nurse Practitioner Note, dated 1/22/24, includes: . Chief Complaint: Impaired status . Patient seen and evaluated per the request of multiple staff members. Upon evaluation patient is sitting in bed elevated approximately 4 to 5 feet off the ground. Educated patient to please leave bed in low position. Patient is slow to respond, and does appear impaired. Pupils are constricted, patient is pale, and takes her time responding. She has been incontinent and states she needs to be cleaned up. Last week patient was found to have Suboxone and pills of gabapentin near her bed. Asked patient if she was doing any illicit drugs, she says she is not. Order written for blood alcohol level and blood drug screen. Patient denies any fever, chills, nausea, vomiting, diarrhea, constipation, shortness breath, or chest pain. She has been sleeping extremely sound, and has been eating fairly. Reviewed facility EHR, medication list, and discussed care in great length with facility staff. Returned a short time later, patient still appearing shaky and impaired. Offered emergency department patient for acute concerns/potential withdrawal. Patient denies wanting to go out. Again returned a short time later after facility staff reported that patient had moonshine at her bedside. Moonshine was confiscated by facility staff, however blood alcohol was already drawn at this point. Facility staff again approached patient about going out for possible withdrawal symptoms and impairment. Patient refuses. Patient is on every 15 minute checks per director of nursing, and will have a blood alcohol and drug screen completed. Advised facility staff that there is to be no alcohol for the patient and any signs or symptoms of worsening patient should be sent out for an acute evaluation due to unknown withdrawal symptoms. R7's lab results, dated 1/22/24, includes: positive for amphetamines, THC- marijuana, TCA- Tricyclic Antidepressants, and Buprenorphine. R7's Physician Order, dated 1/22/24, includes: New Order for no alcohol. R7's Facility Investigation Note, dated 1/24/24, includes: Social Worker met with R7 and a behavior contract was put into place. Son was updated on recent concerns with illicit drug use. Son provided facility with name of visitor that was coming to the facility and visitor logs were reviewed. Police were notified of the name of the visitor who was coming to the facility. R7's Behavior Contract, dated 1/24/24, includes: Resident Conduct/Behavior Contract: signed and dated on 1/24/24 . using illegal/non prescribed substances in the building is a danger to yourself and others . Consequences on noncompliance- involvement of law enforcement and possible notice to discharge given if rules continue to be broken and lead to concerns Resident residing in this building agree to: adhere to the facility rules, policies, and procedures which are in place to both protect resident rights and protect the safety of others. Highlighted rules: no illegal substance use on premises. No taking medications that are not prescribed by our medical provider while residing under their care here. No visitors bringing in illegal substances. Only alcohol approved by Medical Team and distributed appropriately per orders may be consumed on the premises. No sharing, giving, or selling of medications, illegal substances, or alcohol in the facility or on the premises R7's Comprehensive Care Plan, includes: AODA History, Current Concerns, and Risks . Resident has prior history of drug and alcohol use/abuse, and has also used illegal/non-prescribed substances in the facility . Police were informed of finding on 01/24/24. Has been educated on risks . Behavioral/Conduct Contract signed by resident after review . 01/24/24 . R7 sometimes has behaviors which include: Crying. Date Initiated: 01/09/2024 . R7 will be able to feel content/safe/calm and able to discuss her feelings as needed. Date Initiated: 01/09/2024 . Revision on: 01/22/2024 . Target Date: 03/22/2024 . Attempt interventions before any behaviors . begin Date Initiated: 01/09/2024 . Revision on: 01/09/2024 . Give me my medications as my doctor has ordered . Date Initiated: 01/09/2024 . Help me maintain my favorite place to sit . Date Initiated: 01/09/2024 . Make sure I am not in pain or uncomfortable . Date Initiated: 01/09/2024 . Please refer me to my psychologist/psychiatrist as needed . Date Initiated: 01/09/2024 . Speak to me unhurriedly and in a calm voice Date Initiated: 01/09/2024 . Risk for Injury due to drug and alcohol impairment. R7 was found to have suboxone in room and stated a friend had brought them in for her. Visitor has brought in alcohol and other non prescription medications to R7. Date Initiated: 01/22/2024 . Resident will not be under the influence of illegal substances, non prescription medication, or alcohol. Date Initiated: 01/22/2024 . Target Date: 03/22/2024 . 15 minute checks due to impairment . Date Initiated: 01/22/2024 . Drug and alcohol test as order by MD Date Initiated: 01/22/2024 . Educate R7 on facility policy with illegal substances, non prescription medication and alcohol Date Initiated: 01/22/2024 . Educate R7 on risk of taking non prescription medications and illegal substances. Date Initiated: 01/22/2024 . Educate Resident on risk of mixing alcohol and medications. Date Initiated: 01/22/2024 . No alcohol even on special occasions. Date Initiated: 01/22/2024 . Update MD on any signs of impairment Date Initiated: 01/22/2024 (It is important to note the facility did not have care planned goals and interventions related to R7's history of substance abuse until after she had been observed with alcohol and medications that were not prescribed to her. Also, important to note this care plan does not have interventions or goals to address the concern of the friend bringing in illicit and illegal drugs. For example: supervised visits or limited visitation or other interventions that staff can do to mitigate the opportunity of R7 getting illegal and illicit drugs or alcohol.) On 2/21/24 at 11:20 AM, during an interview SW D (Social Worker) indicated services were not offered to R7 related to her diagnosis of substance use disorder. SW D indicated if R7 wanted services related to this she wouldn't even know where to go or who to call as no one in Corporate or in Management has ever gone over this with her. On 2/22/24 at 9:24 AM, during an interview NP L (Nurse Practitioner) indicated she observed R7 to have delayed response, impaired, and slurred speech on more than one occasion. NP L indicated she reported this to management with each incident and she did not feel like the management was doing enough to keep illegal drugs and alcohol out of the hands of residents with known substance use disorders. On 2/22/24 at 12:26 PM, during an interview Anonymous Staff K indicated R7 looked snowed for about 2 weeks, was not able to perform in therapy sessions, and she reported this to management and the nursing team. On 2/22/24 at 2:00 PM, NHA A indicated he didn't know what he could have done differently as he can't infringe on resident rights, like say R7 can't have visitors. Surveyor asked if NHA A knows if this visitor has been here since. NHA A indicated he was not sure. NHA A indicated R7's care plan could contain interventions related to the visitor like supervised visitations, but it doesn't. (It is important to note this visitor has visited the facility since the events above.) According to the National Institute of Health (NIH), in 2016 alone, an estimated 1007 e-cigarette burn injuries were treated in emergency departments across the United States. According to the Food and Drug Administration (FDA): *Delta-8 tetrahydrocannabinol, also known as delta-8 THC, is a psychoactive substance found in the Cannabis sativa plant, of which marijuana and hemp are two varieties. Delta-8 THC is one of over 100 cannabinoids produced naturally by the cannabis plant but is not found in significant amounts in the cannabis plant. As a result, concentrated amounts of delta-8 THC are typically manufactured from hemp-derived cannabidiol (CBD). *Delta-8 THC products have not been evaluated or approved by the FDA for safe use and may be marketed in ways that put the public health at risk. *The FDA received 104 reports of adverse events in patients who consumed delta-8 THC products between December 1, 2020, and February 28, 2022. Of these 104 adverse event reports: 77% involved adults, 8% involved pediatric patients less than [AGE] years of age, and 15% did not report age. 55% required intervention (e.g., evaluation by emergency medical services) or hospital admission. 66% described adverse events after ingestion of delta-8 THC-containing food products (e.g., brownies, gummies). Adverse events included, but were not limited to: hallucinations, vomiting, tremor, anxiety, dizziness, confusion, and loss of consciousness. * Delta-8 THC has psychoactive and intoxicating effects The failure to monitor smoking materials to prevent Residents from smoking in the building, not ensuring residents' smoking materials are accounted for, not ensuring facility staff are properly educated on how to account for resident smoking material and failure to monitor and provide services for Residents with known illicit drug and substance use disorders allowed continued use of illicit drugs for Residents staying at the facility. This created a reasonable likelihood for serious harm for R1, R3, R6, R7, R8, & R10. The Facility removed the jeopardy on 2/23/24 when it had completed the following: ~All staff educated on illicit drug use and smoking policy as it relates to residents. ~Residents educated on facility policy regarding illicit drug use and smoking to include bringing illicit drugs into the facility. ~Staff and residents educated on the expectation of the facility to involve law enforcement for any known illicit drug use while on facility premises. ~ House wide sweep conducted to ensure residents do not have any illicit drugs or smoking materials in their possession. ~ All current residents who smoke had a new smoking assessment completed. ~ Facility policy updated to include obtaining smoking materials after supervised smoking session to be maintained by nursing staff. ~ Facility to monitor residents post smoking session to ensure all smoking materials are retrieved by facility staff. ~ Facility administrator or designee will audit residents rooms daily to ensure smoking materials are secured by facility staff and there are no illicit drugs or paraphernalia present. The deficient practice continues at a scope/severity of E based on the following examples: Example 7 R5 admitted to the facility on [DATE] with the following diagnoses: Alcohol dependence with intoxication, alcohol intoxication with complication, alcohol withdrawal syndrome, cognitive impairment, and alcohol abuse. R5 admitted with a criminal history that consisted of 3 operating while intoxicated charges (OWI). R5's Hospital Discharge, dated 3/15/23, includes, in part: admission date- 2/17/23 . discharge date [DATE] . Discharge Diagnoses: Hypothermia ., alcohol intoxication with complication, alcohol withdrawal syndrome without complication, and cognitive impairment . Hospital course: . was admitted on [DATE], he was found intoxicated and unconscious in the snow and was brought to the emergency department for further evaluation. Was admitted . multiple medical concerns were addressed during hospitalization as following: hypothermia . environmental exposure in the setting of alcohol intoxication . dry eschar left thumb and left second finger tip suspected due to frost bite ., persistent tachycardia. Suspected secondary to alcohol withdrawal ., hypomagnesemia likely due to poor intake and ongoing alcohol abuse, alcohol intoxication on admission with subsequent alcohol withdrawal . After prolonged hospital stay, patient was discharged to skilled nursing facility . with recommendations to continue current medical management . Discharge Instructions: . Refrain from alcohol and drug use . Resources that are available for resident's alcohol abuse: 24 named programs within the community with telephone numbers are listed and 7 online programs with addresses are listed . Community resources/AODA resources in surrounding counties: 19 programs with contact information are listed . Mental Health Resources for patient and family: 20 more resources named with contact information. AODA Counseling providers: 21 listed with telephone numbers and street addresses . Alcohol Use Disorder ([NAME]) is a pattern of alcohol use that includes: problems controlling drinking, always thinking about drinking, continuing to use alcohol even when it causes physical, emotional, social, and money problems, needing to drink more alcohol to get the same effect, having withdrawal symptoms when drinking is stopped . it's a disease in which a person is dependent on a drug- alcohol. This disease can harm the person's physical and mental health. It can also affect their behavior. Untreated it's a disease that gets worse over time. Untreated it can also lead to brain damage and death. Drinking is the main behavior of people with [NAME]. People with [NAME] are at high risk for health problems these include heart disease, mental illness, and cancer. Unless drinking is stopped, it can cause death. Death may result from organ failure, cancer, or common viruses. Death may also result from accidents or suicide. Alcohol can be like a poison to the body. It kills cells. Heavy drinking over a long time can greatly harm the body's organs. These can include the brain, heart, liver, and pancreas. Chronic drinking also harms the digestive tract. It can make the blood thin and unable to clot. This causes bruising and even fatal bleeding. It harms the immune system. This leaves the body at risk for serious disease. [NAME] can lead to a type of distorted thinking. One of the most common forms of this is denial. This is when the person denies that drinking is a problem . Alcohol Abuse: alcoholic drinks harm you when you have too many of them. Drinking that affects your life or your health is called alcohol abuse. Alcohol abuse causes many health problems. The effects depend on how much you drink at one time and how often you drink. Alcohol affects all parts of your body: Brain- alcohol affects the central nervous system. It can damage parts of the brain that control your balance and gait, memory, thinking, and emotions. It can cause memory loss, blackouts, depression, agitation, sleep problems, and seizures. These changes may be long term/permanent. Heart and blood vessels- alcohol can damage heart muscle. This leads to trouble breathing, irregular heartbeat, atrial fibrillation, leg swelling, and heart failure. Alcohol also makes the blood vessel stiff. This causes high blood pressure. All of these problems raise your risk of having a heart attack or stroke. Liver-alcohol causes fat to build up in the liver. Alcohol also raises the risk for hepatitis. This can affect your ability to fight off infections and cause diabetes. The liver changes keep it from removing toxins in your blood that cause brain disease/encephalopathy. The liver changes can also cause the veins in your esophagus and stomach to become thin and swollen with blood. Pancreas-alcohol can cause swelling of the pancreas. Immune System- alcohol weakens your immune system. This makes it harder for you to fight infections and colds. Cancer-alcohol raises the risk for several types of cancer including cancer of the mouth, esophagus, pharynx, larynx, liver, and breast. Home care: these guidelines will help you deal with alcohol abuse: admit you have a problem with alcohol. Get help from people trained in dealing with alcohol abuse. This may be one-on-one counseling or group therapy or it may be an alcohol treatment program. Stay away from people who abuse alcohol or tempt you to drink. Acetaminophen oral tablet: do not drink beverages with alcohol while on this medication . Amlodipine oral tablet: please check with your doctor before drinking alcoholic beverages while on this medication . Neurontin- do not drink beverages with alcohol while on this medicine . Tramadol oral tablet this medicine contains an opioid . do not drink beverages with alcohol while on this medicine . R5's Certified Nursing Assistant (CNA) Kardex, dated 2/21/24, does not include interventions related to R5's known history of alcohol abuse. R5's Comprehensive Care Plan, initiated 3/15/23, includes: initiated 1/30/24 R5's Comprehensive Care Plan, includes: Focus: I sometimes have behaviors which include drinking alcohol on premises against doctor's orders not following facility rules . obtaining things from the store for a fee from other residents. Breaking facility leave of absence policy . Resident has been educated on rules and asked to follow them. Resident has a history of alcohol/other drug abuse. Resident has driven drunk back to the facility January 2024. Resident was incarcerated for DUI/OWI. Upon return resident and family agreed that resident will not keep his car here and cannot use it while residing here. Daughter took car when resident returned . update 2/7/24 resident has an ankle bracelet following incarceration . 2/8/24 behavior contract signed . Goal: my behavior will improve with staff support and intervention. 2/16/24 . Interventions: help me to avoid situations or people that are upsetting to me 1/30/24 . speak to me unhurriedly and in a calm voice 1/30/24 . (It is important to the care plan did not contain interventions related to R5's history of alcohol abuse, interventions for minimizing R5's access to alcohol, plans for treatment related to R5's alcohol abuse, or what staff should do if they find R5 drinking until after he was arrested for his 4th OWI on 1/24/24.) R5's Nurse Notes, contain the following entries: 8/2/23 at 12:11 AM Resident is still out of facility from AM shift. AM nurse reported that resident left this morning. Resident signed out this morning and hasn't returned. 8/4/23 at 7:35 AM At 7:15 AM observed resident asking another resident to come to his room. Resident attempted to hand him an open bottle of liquor. Writer explained risks and resident gave bottle to writer. Resident then asking for his pills/ Writer entered resident's room and resident sitting on top of his bed and was given medicine. Resident bent over to pick up can off of the floor which resident had 2 open cans of [NAME] Light. Again risks explained . Writer removed a bag of empty beer cans and empty cigarette packs per resident's request. Writer contacted emergency department and consulted . Continue plan of care . 10/3/23 at 3:00 PM resident arrives 2 facility oriented times 4 in good spirits and cooperative but does have alcohol odor on his breath . PM meds given per his request . oxycodone held due to alcohol consumption . R5's Wisconsin Circuit Court Public Records, dated 1/24/24, includes: . statute 346.63 (1)(a) . Description: OWI 4th . Severity: Felony H . 1/26/24 Defendant to comply with ID processing, absolute sobriety, defendant is not to possess or consume any alcohol. Defendant is not to use/possessany controlled substances without a valid prescription and take as prescribed. Defendant is not to use/possess any drug paraphernalia. Defendant is not to operate a motor vehicle unless properly licensed. The defendant is ordered to comply with C AM monitoring through Wisconsin Correctional System/Wisconsin Community Services. Scram Cam manufacturer's recommendations for use, includes: Like a breathalyzer for the ankle, the Scram Continuous Alcohol Monitoring (SCRAM CAM) bracelet provides 24/7 transdermal alcohol testing for hardcore drunk drivers, high-risk alcohol and domestic violence caseloads. By automatically sampling the wearer's perspiration every 30 minutes, the SCRAM CAM bracelet eliminates testing gaps and encourages accountability. SCRAM CAM not only supports sobriety but also results in higher compliance rates with court orders and increases community safety. R5's Nurse Note, dated 1/30/24 at 5:21 PM, included: Resident returned to facility today. Per discussion yesterday and today with resident, administration., social services department, and unit manager, resident agreed that he will not keep his car here at the facility anymore due to his dangerous behavior/DUI history. Daughter dropped resident off and left in his car. R5's Resident Conduct/Behavior Contract, dated 2/8/24, includes: . using illegal/non prescribed substances in the building is a danger to yourself and others . Consequences on noncompliance- involvement of law enforcement and possible notice to discharge given if rules continue to be broken and lead to concerns Resident residing in this building agree to: adhere to the facility rules, policies, and procedures which are in place to both protect resident rights and protect the safety of others. Highlighted rules: no illegal substance use on premises. No taking medications that are not prescribed by our medical provider while residing under their care here. No visitors bringing in illegal substances. Only alcohol approved by Medical Team and distributed appropriately per orders may be consumed on the premises. No sharing, giving, or selling of medications, illegal substances, or alcohol in the facility or on the premises R5's Comprehensive Care Plan, as of 2/18/24, includes: Focus: I sometimes have behaviors which include drinking alcohol on premises against doctor's orders not following facility rules . obtaining things from the store for a fee from other residents. Breaking facility leave of absence policy . Resident has been educated on rules and asked to follow them. Resident has a history of alcohol/other drug abuse. Resident has driven drunk back to the facility January 2024. Resident was incarcerated for DUI/OWI. Upon return resident and family agreed that resident will not keep his car here and cannot use it while residing here. Daughter took car when resident returned . update 2/7/24 resident has an ankle bracelet following incarceration . 2/8/24 behavior contract signed . Goal: my behavior will improve with staff support and intervention. 2/16/24 . Interventions: help me to avoid situations or people that are upsetting to me 1/30/24 . speak to me unhurriedly and in a calm voice 1/30/24 . (It is important to note although R5's Care Plan has been updated to include his history of alcohol abuse it still does not contain interventions related to what staff should monitor for, what they should do if they see R5 drinking alcohol with his ankle monitor on, and what the facility will do to offer R5 services for his alcohol abuse.) On 2/21/24 at 11:20 AM during an interview, SW D (Social Worker) indicated R5 was not offered services related to his alcohol abuse history and he should have been. SW D indicated if R5 wanted services she wouldn't even know where to begin with arranging them as no one has ever instructed her regarding this. SW I indicated R5's care plan should have identified him to be at risk of alcohol abuse and it should have contained in[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of the facility's policy, the facility failed to assess the risk, advise of the risk and/or benefits, and obtain consent prior to use of bed rails with air mattresses for 8 residents (R23, R11, R16, R18, R19, R24, R25, and R28) on the skilled unit. R23's bed was equipped with an alternating air mattress as well as bed rails so she could assist with bed mobility. On 12/23/23, R23 was having a hard time breathing and wanted to get up. R23 was found entrapped between the bed rail and the air mattress. Facility staff were able to free her and began CPR (Cardio Pulmonary Resuscitation) which was unsuccessful. R11, R16, R18, R19, R24, R25, and R28 were also found to be using bed rails without a risk assessment, without being advised of the risks and benefits of the side rails, and without obtaining informed consent for their use. The failure to assess the risks of the side rail use with an alternating air mattress, advise the resident or their representative of the risks and benefits of the side rails as well as obtaining informed consent prior to the use created a finding of immediate jeopardy that began on 12/23/23. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) was notified of the immediate jeopardy on 1/19/24 at 9:25 a.m. The immediate jeopardy was removed on 1/19/24. However, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to to implement its action plans. Findings include: The facility policy titled Proper Use of Bed Rails, dated 10/01/22, indicated: Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Definitions: Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail . Policy Explanation and Compliance Guidelines: Resident Assessment 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Size and weight c. Sleep habits d. Medication(s) e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility (in and out of bed) l. Risk of falling 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include: a. Accident hazards (e.g., falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard) b. Barrier to residents from safely getting out of bed c. Physical restraint (e.g., hinders residents from independently getting out of bed or performing routine activities) d. Decline in resident function, such as muscle functioning/balance e. Skin integrity issues f. Decline in other areas of activities of daily living such as using the bathroom, continence, eating, hydration, walking and mobility g. Other potential negative psychosocial outcomes such as an undignified self-image, altered self-esteem, feelings of isolation, or agitation/anxiety. 4. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself Informed Consent 6. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. 7. The information that the facility should provide to the resident, or resident representative includes, but is not limited to: a. What assessed medical needs would be addressed by the use of bed rails; b. The resident's benefits from the use of bed rails and the likelihood of these benefits; c. The resident's risks from the use of bed rails and how these risks will be mitigated; and d. Alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate . Review of the blank Bed Rail Assessment provided by the facility revealed the assessment reviewed the following areas: 1. Information 1. Is the resident Non-Ambulatory? 2. Does the resident's level of consciousness fluctuate? 3. Does the resident have alteration in safety awareness due to cognitive decline? 4. Does the resident have history of falls? 5. Has the resident displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed? 6. Does the resident have difficulty with balance or poor trunk control? 7. Does the resident have difficulty with postural hypertension? 8. Has the resident expressed a desire to have Side Rails/Assist Bar for safety and/or comfort? 9. Is the resident visually challenged? 2. Interventions . 2. Select all interventions that apply to this resident a. Lower the bed to the floor b. Provide restorative care to enhance abilities to safely stand and walk c. Provide frequent staff monitoring at night d. Provide assisted toileting for the resident at night e. Visual and verbal reminders to use the call bell f. Other 3. Side Rail Placement . 3. Side rail replacement recommendations a. None b. Left c. Right d. Bilateral 3a. Side Rail Placement: a. Side Rails/Assist Bar are indicated and serve as an enabler to promote independence b. The resident has expressed a desire to have Side Rails/Assist Bar c. Side Rails/Assist Bar are not indicated at this time This assessment did not address the risk associated with the use of side rails with an air mattress, include documentation of the advisement of the risks and benefits of having bed rails, or show that the resident or resident representative signed an informed consent for the use of bed rails. According to the US Food and Drug Administration's Recommendations for Consumers and Caregivers about Adult Portable Bed Rails, Use caution when using bed rails with a soft mattress as this may increase risk of entrapment between the mattress and bed rail. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or waterbed. R23 was admitted to the facility on [DATE] with medical diagnoses that included cellulitis (infection of the tissues), type II diabetes, anxiety, chronic pain syndrome, muscle wasting, difficulty in walking, and unsteadiness on feet. R23 had an admission weight of 396.9 pounds and was able to transfer with a gait belt, walker, and assistance of one. Review of R23's EMR did not find a bed rail assessment in the record. Upon request, the facility provided Bed Rail Assessment, dated 12/14/23. The assessment indicated R23 requested rails for positioning in bed and to assist with getting out of bed. R23 was ambulatory, did not have a fluctuating level of consciousness, no history of falls, did not display poor bed mobility or difficulty moving to a sitting position at the side of the bed, did not have difficulty with balance or poor trunk control, had no postural hypertension, and was not visually challenged. Based on this assessment a decision was made that bed rails were indicated to serve as an enabler to promote independence. This assessment did not include the risk of using bed rails with an air mattress or take into consideration the compression effect of R23's weight of 396.9 pounds causing increased size of gaps between the mattress and the bed rail. During an interview with a complainant on 01/17/24 at 10:48 AM, the surveyor was advised of a death in facility on 12/23/23 where a resident was entrapped by a side rail. R23's electronic medical record (EMR) included a Progress Note dated 12/23/23 at 3:39AM that stated, At approx [approximately] 0330 [3:30 AM] the body was taken by coroner [name]. [Medical Examiner name] was given all paperwork including progress notes from admission and statements . A second entry stated, Effective Date: 12/23/2023 02:15 [2:15 AM] Type: eMar - Shift Level Administration Note Text: At approx 0040 [12:40 AM] residents [sic] bathroom light came on. As I was going to the room; the CNA C [Certified Nursing Assistant] came to doorway requesting help. The resident had slowly slid out of bed while she was there. We got her head and arm out from between the bed and railing. She was face down and the CNA had placed pillows to protect her head. The resident was not breathing. Writer verbally called other nurse. Together we were able to roll her over and position her to begin CPR. While other nurse started compressions; writer called 911. Writer then took over compressions while other nurse retrieved the AED [automated external defibrillator] unit. Paramedics then arrived and took over. DON [Director of Nursing] notified, coroner notified, sister notified, Dr .notified. R23 was pronounced dead at the facility. During an interview on 01/17/24 at 1:32 PM, NP D (Nurse Practitioner) stated, I was aware of R23 expiring but did not know the circumstances. NP D continued, Last Thursday (1/10/24), NHA A (Nursing Home Administrator) requested I attend a reenactment of the death with the coroner. NP D stated the coroner did not show up; however, the reenactment was verbally walked through. NP D stated, T the CNA relayed that the resident wanted to get up due to difficulty breathing, the resident stood up and sat down 3 times; on the third sit down, the resident was put back in bed, but due to R23's weight, CNA C was unable to center her and the resident was angled in the bed. CNA C went to the bathroom to use the call light so staff knew she needed assistance now. When she returned to the bed, the resident had slid down with her lower body and abdomen on the floor and her head was lodged by the side rail. CNA C left the room to get help. When the LPN (Licensed Practical Nurse) and CNA C arrived they lifted the resident from between the rail and the mattress and laid her flat on the floor. CPR was started and EMS called. During an interview on 01/18/24 at 12:08 AM, CNA C stated R23 had been short of breath and unable to stand, sitting back down and doing deep breathing. During the last attempt to stand R23 sat then laid down on the bed, angled across the mattress, and CNA C was unable to straighten her. The resident was complaining she could not breathe and raised the head of the bed. CNA C had activated the room call light for assistance and went into the bathroom to use the emergency call light for assistance. As CNA C exited the bathroom, R23 slid down and rolled over as she slid out of bed, lodging her head in the rail. When asked to clarify, CNA C stated R23's head was between the mattress and rail. LPN E was interviewed on 01/18/24 at 12:27 AM and stated she was not the one that assisted CNA C to extricate R23 and by the time she got to the room R23 was non-responsive and blue, and CPR was started. On 1/18/24 at 6:00 PM, Surveyor along with NHA A and DON B measured R23's unoccupied bed with the air mattress and bed rails in place. The measurements revealed a gap at the end of the bed of 2.5 inches, at the foot of bed was a gap of 4 inches, a 2 inch gap at the left side rail, and a 2.75 inch gap at the right side rail. The air mattress on R23's bed was identified as the Protekt Aire 8000. Review of the facility provided air mattress manufacturer documentation titled, Proactive Medical Products Protekt Aire 8000 Operation Manual revealed that the manual did not address the use of bed rails with the air mattress. During an interview on 01/19/24 at 1:40 PM, NHA A stated an expectation that all rails would be assessed, risks and benefits advised, the rails are care planned, and an informed consent is obtained as the policy states. Observation of the skilled unit on 01/18/24 at 10:15 AM and review of the EMR Assessments tab for each of the following residents. Review of the bed rail assessments for these residents revealed the same assessment as described above was used. These bed rail assessments did not address the increased risk of entrapment with the use of bed rails with air mattresses. ~R11 had an air mattress with bed rails; the bed rail assessment was completed on 09/06/23 and 10/02/23. ~R16 had an air mattress with bed rails; the bed rail assessment was completed on 11/17/23. ~R18 had an air mattress with bed rails; the bed rail assessment was completed on 01/10/24. ~R19 had an air mattress with bed rails; had an incomplete bed rail assessment started on 12/18/23. ~R24 had an air mattress with bed rails; the bed rail assessment was completed on 12/13/23 and 12/22/23. ~R25 had an air mattress with bed rails; the bed rail assessment was completed on 10/02/23. ~R28 had an air mattress with bed rails; the bed rail assessment was completed on 12/01/23. The failure to assess the risks of the side rail use with an alternating air mattress, advise the resident or their representative of the risks and benefits of the side rails as well as obtaining informed consent prior to the use created a finding of immediate jeopardy. The facility removed the jeopardy on 1/19/24 when it had completed the following: 1. Completed a house wide sweep to ensure all resident with siderails and air mattresses had assessments, orders, care plans, and risk/benefits in place; 2. Completed gap assessments to ensure the gap was not greater than 2.5 inches; 3. Licensed nurses and therapy staff were educated on entrapment risks for residents using air mattresses or residents with increased movement or cognitive impairment. All staff to be educated prior to beginning their next scheduled shift. 4. Educated maintenance staff on performing gap assessments. Education provided before the next scheduled shift. 5. DON or designee will audit 5 residents weekly for 6 weeks to ensure the process is following with the initiation of side rails including risk/benefits, orders, alternative interventions tried/failed, care plans, and gap assessments. Result of the audits will be reported to QAPI (Quality Assurance Program Improvement) for further direction.