Chandler Post Acute And Rehabilitation

Base on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to monitor and ensure that resident (#34) was administered pain and psychotropic medications as per the orders and medications were left with the resident unsupervised.

Findings include:

Resident #34 was admitted to the facility on May 25, 2023 and readmitted on September 8, 2024 with diagnoses that included post traumatic disorder, anxiety, major depression, low back pain, and chronic pain syndrome.

The care plan dated May 26, 2023 revealed that the resident is on pain medication therapy related to pain. Interventions included to administer medication as ordered.

Review of the care plan dated May 29, 2023 revealed that the resident is on anti-anxiety mediation due to anxiety as evidenced by restlessness. Interventions included to give anti-anxiety medications as ordered by the physician.

The minimum data set (MDS) dated October 11, 2024 included that the resident's memory is okay and she is able to make decisions independently.

The order summary revealed:
-April 10, 2024, Gabapentin capsule 400 mg give 2 capsules by mouth every 6 hours for neuropathy. Hold from October 11, 2024 to October 14, 2024.
-April 12, 2024, Xtampza ER oral capsule ER 12 hour abuse-deterrent 27 mg (Oxycodone) give 1 capsule by mouth two times a day for pain.
-April 14, 2024, monitor behavior every shift for anti-anxiety episodes as evidenced by target behavior, restlessness.
-June 14, 2024, Oxycodone HCl oral tablet 15 mg (Oxycodone HCl) give 1 tablet by mouth every 6 hours for pain. Hold from October 11, 2024 to October 14, 2024.
-July 31, 2024, Alprazolam tablet 0.5 mg give one tablet orally every 12 hours for anxiety as evidenced by restlessness.
-October 27, 2024, Xtampza ER oral capsule ER 12 hour abuse-deterrent 27 mg give 1 capsule by mouth one time only for pain for one day.

The medication administration record (MAR) dated October 27 2024 revealed:
-Oxycodone HCl oral tablet 15 mg (Oxycodone HCl) give 1 tablet by mouth every 6 hours for pain was administered at 6:00 a.m.
-Gabapentin capsule 400 mg give 2 capsules by mouth every 6 hours for neuropathy was administered at 6:00 a.m.
-Alprazolam tablet 0.5 mg give 1 tablet orally every 12 hours for Anxiety as evidenced by restlessness was not administered at 8:00 a.m.
-Xtampza ER oral capsule ER 12 hour abuse-deterrent 27 mg (Oxycodone) give 1 capsule by mouth two times a day for pain was not administered at 8:00 a.m.
-Xtampza ER oral capsule ER 12 hour abuse-deterrent 27 mg give 1 capsule by mouth one time only for pain for one day was administered at 3:15 p.m.

A behavior note dated October 16, 2024 by a licensed practical nurse (LPN/staff #48) revealed that the resident was compliant with taking her medications, but requires observation due to losing them or dropping her medications on herself.

A progress note dated October 27, 2024 by a (RN/staff #33) revealed that the nurse received a report that the resident takes her medications in pudding. The nurse brought the resident her morning medications that contained controlled substances in pudding; the resident became immediately agitated that the medications weren't separated into a separate cup and threw them on the floor. The nurse informed the resident that controlled substances would not be re-pulled. The resident subsequently refused all care from the nurse, including afternoon medications, and removed her supplemental oxygen in protest. The nurse informed the Assistant Director of Nursing (ADON) and the medical doctor. The medical doctor stated that he would come and see the resident.

A progress note dated October 27, 2024 by (RN/staff #33) revealed that the physician cleared a one-time dose of pain medication for the resident.

A behavior note dated October 29, 2024 by a (LPN/staff #42) revealed that the resident was compliant with taking her medications and appeared to be in a positive mood. She was watched while taking her medications to make sure that did not drop or hide anything.

An interview was conducted on November 1, 2024 with (RN/staff #33), who stated that he had provided care for resident #33 on prior occasions. He went to her room to administer her morning medications between 8:00 and 9:00 a.m. He stated that he received a report that the resident receives her medication in pudding, but she wanted to see the medications, so she could identify them and choose which medications that she wanted to take, but they were already dissolving, so they were not recognizable. He stated that the resident told him that she is usually given her medication on the side with the pudding and he told the resident that was fine, but he could not pull the narcotics again, so she would have to take the medications in the pudding. He stated that a certified nursing assistant (CNA/staff 8#) was in the resident's room when he left to get the resident some water, but the resident normally takes the medications just with pudding, and when he returned the CNA told him that the resident had thrown the pudding with the medications on the floor, so he had to throw it all away. He stated that he did not know if the resident was allowed to take her medication without supervision, but based on his training, he is supposed to watch the resident take the medication to verify that it was taken and to ensure that the resident doesn't aspirate. He stated that once the medications were on the floor, he told the resident that she would have to wait until the next time that the medications were scheduled to be administered and this included the pain and anti-anxiety medication. He stated that there is a risk of continued pain and withdrawal when pain medications are not administered as ordered, and there is a risk of agitation if anti-anxiety medications are not administered as per orders. He thought that the pain medication and anti-anxiety medication was due again sometime in the evening. He stated that he didn't contact the physician right away, but continued to monitor the resident, and around mid afternoon, the resident complained of pain, removed her oxygen, became aggressive and was still upset about not receiving her medications in the morning. He stated that he contacted the physician around 1:00 p.m.; the physician was in the facility and told him that he would come by and see the resident. He stated that it is not within his purview to decide if a resident should get medication or not and the normal process would be to call another nurse to witness the medications being thrown away and pull more pain and anti-anxiety medication for the resident, but the medication had dissolved, so another nurse would not be able to identify the medications to witness that the medication was thrown away. He stated that he did not contact the ADON or DON because he was the charge nurse that day.

During a second interview with (RN/staff #33) conducted on November 1, 2024 at approximately 11:15 a.m., he reviewed the medication administration record (MAR) dated October 2024 and stated that the resident refused all medications on the morning of October 27, 2024 when he wouldn't pull another Xtampza ER oral capsule for pain and Alprazolam for anxiety. He stated that the resident did not receive any medication on the morning of October 27, 2024, and if he documented that the resident did receive a medication, it is a documentation error.

An interview was conducted on November 1, 2024 with a certified nursing assistant (CNA/staff #8), who stated that the resident's call-light was on and she was walking towards the resident's room when she heard raised voices. She stated that she could hear (RN/staff #33) and the resident were both yelling, so she didn't go into the room. Staff #33 came out of the room and said, "

Based on review of documentation, photographs, staff interviews, and the facility policy and procedure, the facility failed to provide physical health services that protect the health and safety of one resident(#1).

Findings include:

Resident #1 was admitted to the facility on January 16, 2024 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified fracture of thoracic vertebrae 5 and 6, subsequent encounter for fracture with routine healing , hypertension, and hypotension.

The order summary revealed an order for aspirin tablet chewable 81 milligram (mg) one tablet by mouth one time a day for clotting prevention dated January 16, 2024; ticagrelor oral tablet 90 mg one tablet by mouth for clotting prevention dated January 16, 2024, the order discontinued and request for stop date not provided; and ticagrelor oral tablet 90 mg give one tablet by mouth every 12 hours for coronary artery disease (CAD) dated January 19, 2024, the order was discontinued and request for stop date not provided.

Review of the care plan did not reveal a plan for hypertension, coronary artery disease, or the use of anticoagulants.

The minimum data set (MDS) assessnebt dated January 22, 2024 included a brief interview for mental status score of 12 indicating moderate cognitive impairment.

Review of a weekly skin evaluation dated January 30, 2024 did not reveal any new skin issues.

Documentation dated February 3, 2024 at 12:27 p.m. revealed that a licensed practical nurse (LPN/staff #244) sent pictures of the resident's left foot/lower leg and the left knee/thigh to the physician stating that everyone said this was new bruising; the resident was on an acetylsalicylic acid (aspirin) and ticagelor. Documentation revealed at 12:30 p.m., the physician stated to get an X-ray of the knee and foot; to hold the aspirin (acetylsalicylic acid) for two days; and, check for blood clotting factors to include PT (prothrombin time), PTT (partial thromboplastin time), INR (international normalized ration) with CBC (complete blood count) in the morning. There was no mention that the left leg was cool to the touch.

Documentation dated February 3, 2024 at 1:23 p.m. revealed that (LPN/staff #244) sent a second message to the physician stating that a registered nurse (RN/staff #92) stated that the resident was not really eating or drinking, and resident had a peripheral (IV), and asked if the physician would like to start fluids. The documentation revealed at that at 1:24 p.m. the physician responded stating to give the resident a liter of .9 normal saline at 60 milliliter (mL)/hour. There was no mention that the left leg was cool to the touch.

A progress note dated February 3, 2024 at 2:02 p.m. revealed that resident #1's left leg from the upper thigh area to the toes was cool to the touch and red blotchy in appearance; pulses were present; flushed foley with red tinged urine flowing; physician notified and orders received for IV fluids at 60 mL/hr and X-ray ordered for knee and ankle.

The order summary revealed an order dated February 3, 2024, x-ray left knee and foot one time only for bruising and swelling for one day and completed February 4, 2024.

The order summary revealed an order dated February 4, 2024, PT/INR, PTT, CBC in the morning for bruising for one day and discontinued February 5, 2024.

A progress note dated February 4, 2024 at 6:46 a.m. revealed that the resident was admitted to the hospital intensive care unit for a myocardial infarction, stroke, and blood clots in the bottom left extremity.

A progress note dated February 5, 2024 at 10:50 a.m. revealed that the resident passed away in the morning at the hospital.

The medication administration record (MAR) dated February 2024 revealed:
-January 16, 2024, Aspirin tablet chewable 81 mg give one tablet by mouth one time a day for clotting prevention was administered February 1, 2, and 3, 2024.
-January 19, 2024, Ticagrelor oral tablet 90 mg give one tablet by mouth every 12 hours for coronary artery disease (CAD) was administered February 1, 2, and 3, 2024.
-February 3, 2024, x-ray left knee and foot one time only for bruising an swelling for one day was completed on February 3, 2024.
-February 4, 2024, PT/INR, PTT, CBC in the morning for bruising for one day and was not completed due to the resident being transferred to the hospital.

An interview was conducted on April 2, 2024 at 9:34 a.m. with a registered nurse (RN/staff #92), who stated that when she is assessing a resident for pedal pulses and femoral pulses in the lower extremities, she compares the color, temperature, and pulse in both extremities to identify differences between the two. She asks the resident if he or she is experiencing tingling or numb sensations. She stated that a white color in the skin indicates hypoxia, a lack of oxygen, and a red, blue, purplish color indicates perfusion. She stated that when she assessed resident #1's left and right lower extremities on February 3, 2024, there was a difference in temperature and color. The left extremity was cooler to the touch and a purple blotchy color. She observed that the higher up the thigh, the more purplish the blotchiness. She stated that it is best practice to use a scale from 1 to 4 when assessing the intensity of the pulse, 1 being faint and 4 indicating a bounding pulse. She stated that using a scale to assess intensity allows her to determine if there was a difference or a change in pulse intensity, which may indicate a problem, but she did not use the scale to assess the resident and therefore, did not did not determine a baseline for pedal pushes, so she could not really assess a change in condition. She stated that she checked that a pedal pulse was present and continued to check every hour until the X-ray technician arrived, but she did not document the assessments in the progress notes. Staff #92 reported to the charge nurse (LPN/staff #244) and staff #244 contacted the physician.

An interview was conducted on April 2, 2024 at 11:06 a.m. with (LPN/staff #244), who stated that she was notified by a certified nursing assistant (CNA) that the resident had new bruises on the left leg. She stated that she assessed the resident's left leg and observed there was new bruising around the knee and on the dorsal side of the foot, but the red/purplish discoloration could have been mottling, which would have indicated a lack of blood flow. Then she stated that she thought the blotchy discoloration and not mottling. She stated that if mottling was present, pedal pulses would need to be checked and the facility doesn't use the intensity scale to assess pedal pulses, they only check that a pedal pulse is present. Then she stated that she did not remember if the left leg was cool to the touch, blotchy in color, or if staff #92 was present during the assessment. Then she stated that the left leg was warm to the touch. She stated that she did not document her assessment and told staff #92 to complete the documentation. She stated that she contacted the physician to report new bruising around the knee and dorsal side of the left foot and the physician ordered an X-ray and to hold the blood thinners for three days. She stated that staff #92 should have told her that the resident's left leg was cool to the touch because she thought that the resident had bruising from an unknown injury, but did not report the injury of unknown origin to the Director of Nursing or the state agency. She stated that she was later told that the resident had blood clots in the lower extremities.

An interview was conducted on April 2, 2024 at 12:42 p.m. with the Director of Nursing (DON/staff #7), who stated that if a resident's leg was cool from the thigh to the toe, it was an expectation that the pedal

Based on review of documentation, photographs, staff interviews, and the facility policy and procedure, the facility failed to provide services in accordance with professional standards of practice for one resident (#1). The deficient practice could result in appropriate services not being identified and provided to residents.

Findings include:

Resident #1 was admitted to the facility on January 16, 2024 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified fracture of thoracic vertebrae 5 and 6, subsequent encounter for fracture with routine healing , hypertension, and hypotension.

The order summary revealed an order for aspirin tablet chewable 81 milligram (mg) one tablet by mouth one time a day for clotting prevention dated January 16, 2024; ticagrelor oral tablet 90 mg one tablet by mouth for clotting prevention dated January 16, 2024, the order discontinued and request for stop date not provided; and ticagrelor oral tablet 90 mg give one tablet by mouth every 12 hours for coronary artery disease (CAD) dated January 19, 2024, the order was discontinued and request for stop date not provided.

Review of the care plan did not reveal a plan for hypertension, coronary artery disease, or the use of anticoagulants.

The minimum data set (MDS) assessnebt dated January 22, 2024 included a brief interview for mental status score of 12 indicating moderate cognitive impairment.

Review of a weekly skin evaluation dated January 30, 2024 did not reveal any new skin issues.

Documentation dated February 3, 2024 at 12:27 p.m. revealed that a licensed practical nurse (LPN/staff #244) sent pictures of the resident's left foot/lower leg and the left knee/thigh to the physician stating that everyone said this was new bruising; the resident was on an acetylsalicylic acid (aspirin) and ticagelor. Documentation revealed at 12:30 p.m., the physician stated to get an X-ray of the knee and foot; to hold the aspirin (acetylsalicylic acid) for two days; and, check for blood clotting factors to include PT (prothrombin time), PTT (partial thromboplastin time), INR (international normalized ration) with CBC (complete blood count) in the morning. There was no mention that the left leg was cool to the touch.

Documentation dated February 3, 2024 at 1:23 p.m. revealed that (LPN/staff #244) sent a second message to the physician stating that a registered nurse (RN/staff #92) stated that the resident was not really eating or drinking, and resident had a peripheral (IV), and asked if the physician would like to start fluids. The documentation revealed at that at 1:24 p.m. the physician responded stating to give the resident a liter of .9 normal saline at 60 milliliter (mL)/hour. There was no mention that the left leg was cool to the touch.

A progress note dated February 3, 2024 at 2:02 p.m. revealed that resident #1's left leg from the upper thigh area to the toes was cool to the touch and red blotchy in appearance; pulses were present; flushed foley with red tinged urine flowing; physician notified and orders received for IV fluids at 60 mL/hr and X-ray ordered for knee and ankle.

The order summary revealed an order dated February 3, 2024, x-ray left knee and foot one time only for bruising and swelling for one day and completed February 4, 2024.

The order summary revealed an order dated February 4, 2024, PT/INR, PTT, CBC in the morning for bruising for one day and discontinued February 5, 2024.

A progress note dated February 4, 2024 at 6:46 a.m. revealed that the resident was admitted to the hospital intensive care unit for a myocardial infarction, stroke, and blood clots in the bottom left extremity.

A progress note dated February 5, 2024 at 10:50 a.m. revealed that the resident passed away in the morning at the hospital.

The medication administration record (MAR) dated February 2024 revealed:
-January 16, 2024, Aspirin tablet chewable 81 mg give one tablet by mouth one time a day for clotting prevention was administered February 1, 2, and 3, 2024.
-January 19, 2024, Ticagrelor oral tablet 90 mg give one tablet by mouth every 12 hours for coronary artery disease (CAD) was administered February 1, 2, and 3, 2024.
-February 3, 2024, x-ray left knee and foot one time only for bruising an swelling for one day was completed on February 3, 2024.
-February 4, 2024, PT/INR, PTT, CBC in the morning for bruising for one day and was not completed due to the resident being transferred to the hospital.

An interview was conducted on April 2, 2024 at 9:34 a.m. with a registered nurse (RN/staff #92), who stated that when she is assessing a resident for pedal pulses and femoral pulses in the lower extremities, she compares the color, temperature, and pulse in both extremities to identify differences between the two. She asks the resident if he or she is experiencing tingling or numb sensations. She stated that a white color in the skin indicates hypoxia, a lack of oxygen, and a red, blue, purplish color indicates perfusion. She stated that when she assessed resident #1's left and right lower extremities on February 3, 2024, there was a difference in temperature and color. The left extremity was cooler to the touch and a purple blotchy color. She observed that the higher up the thigh, the more purplish the blotchiness. She stated that it is best practice to use a scale from 1 to 4 when assessing the intensity of the pulse, 1 being faint and 4 indicating a bounding pulse. She stated that using a scale to assess intensity allows her to determine if there was a difference or a change in pulse intensity, which may indicate a problem, but she did not use the scale to assess the resident and therefore, did not did not determine a baseline for pedal pushes, so she could not really assess a change in condition. She stated that she checked that a pedal pulse was present and continued to check every hour until the X-ray technician arrived, but she did not document the assessments in the progress notes. Staff #92 reported to the charge nurse (LPN/staff #244) and staff #244 contacted the physician.

An interview was conducted on April 2, 2024 at 11:06 a.m. with (LPN/staff #244), who stated that she was notified by a certified nursing assistant (CNA) that the resident had new bruises on the left leg. She stated that she assessed the resident's left leg and observed there was new bruising around the knee and on the dorsal side of the foot, but the red/purplish discoloration could have been mottling, which would have indicated a lack of blood flow. Then she stated that she thought the blotchy discoloration and not mottling. She stated that if mottling was present, pedal pulses would need to be checked and the facility doesn't use the intensity scale to assess pedal pulses, they only check that a pedal pulse is present. Then she stated that she did not remember if the left leg was cool to the touch, blotchy in color, or if staff #92 was present during the assessment. Then she stated that the left leg was warm to the touch. She stated that she did not document her assessment and told staff #92 to complete the documentation. She stated that she contacted the physician to report new bruising around the knee and dorsal side of the left foot and the physician ordered an X-ray and to hold the blood thinners for three days. She stated that staff #92 should have told her that the resident's left leg was cool to the touch because she thought that the resident had bruising from an unknown injury, but did not report the injury of unknown origin to the Director of Nursing or the state agency. She stated that she was later told that the resident had blood clots in the lower extremities.

An interview was conducted on April 2, 2024 at 12:42 p.m. with the Director of Nursing (DON/staf

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that changes in resident #491 condition will be communicated to the physician. The deficient practice could result in delayed treatment.

Findings include:

Resident #491 was admitted on September 7, 2023, with diagnoses of traumatic hemorrhage of cerebrum without loss of consciousness, wedge compression fracture of T11-T12 vertebra, fracture of the lower end of right radius and lower end of right ulna, dementia, essential primary hypertension, and atrial fibrillation.

Record review dated September 8, 2023, revealed the following orders: aspirin 81 mg give one tablet by mouth one time a day for CVA prophylaxis, Lisinopril oral tablet 2.5 mg give one tablet by mouth one time a day for hypertension, and Amiodarone HCL oral tablet 200 mg give two tablets by mouth every 12 hours for atrial fibrillation for 7 days then give one tablet by mouth one time a day for atrial fibrillation for 23 days.

Record review dated September 8, 2023, revealed resident had a hypertension care plan with a goal to remain free of complication related to hypertension. The interventions included to give anti hypertensive medications as ordered, to monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness, to monitor for and document any edema and notify MD, to monitor/document abnormalities for urinary output and report significant changes to the MD, to monitor/document/report to MD as needed any signs and symptoms of malignant hypertension such as headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (Dyspnea), and to monitor/record medication side effects and report to MD as necessary.

On September 11, 2023, Interdisciplinary Team (IDT)-Brief Interview for Mental Status (BIMS) record revealed resident score was 0.0, a severe cognitive impairment.

The Minimum Data Set (MDS) dated September 13, 2023 revealed resident have a memory problem for short- and long-term memory; resident cognitive skills for daily decision making is severely impaired; resident required extensive assistance for bed mobility, transfer, dressing, eating, toilet use, personal hygiene; and resident required total dependence for bathing.

During the review of vital signs, record review revealed the resident had a systolic blood pressure that ranges from 112 millimeter of mercury to 168 millimeters of mercury, and a diastolic blood pressure ranges from 68 millimeter of mercury to 89 millimeters of mercury since admission, except on September 17, 2023 at 07:29, record revealed the resident had a one-time episode of a blood pressure of 168/110.

A physician progress note dated September 17, 2023 at 10:20 AM revealed, Patient lying in bed and no apparent distress. Seeing at around 9:50 AM. Not as talkative today. Appears comfortable. Blood Pressure: 168/110 September 17, 2023 at 7:29 AM. History of atrial fibrillation-on Amiodarone. On aspirin. Remains sinus on auscultation. Occasionally has an extra beat but remains in sinus. Follow up with cardiology. Hypertension-BP elevated. Monitor - on Lisinopril.

During the review of vital signs, record review revealed the resident had a pulse rate that ranges from 54 beats per minute regular rate to 98 beats per minute regular rate since admission. But on September 18, 2023 at 6:36 AM, record revealed the resident had a new onset irregular pulse rate of 115 beats per minute.

During the review of vital signs, record review revealed the resident had a respiration rate that ranges from 16 breaths per minute to 22 breaths per minute since admission. But on September 18, 2023 at 6:36 AM, record revealed the resident had respiration of 26 breaths per minute.

There was no evidence found in the clinical record that the resident's physician was notified of the resident's blood pressure reading of 168/110 on September 17, 2023 at 7:29 AM. There was no evidence found in the clinical record that the resident physician was notified of the resident's new onset irregular heart rate of 115 beats per minute on September 18, 2023 at 6:36 AM, and there was no evidence in the clinical record that the resident's physician was notified regarding resident's status on September 18, 2023 "upon entering the patient's room this morning during shift report the patient was seen breathing heavily, ADON was called into the room. Oxygen saturation were reading at 97%. Frequent checks were provided to the patient and the daughter was called and left a VM (voice message)."

Record review revealed on September 18, 2023 at 8:20 AM, "therapy and CNA walked in the room and the patient was seen unresponsive, no pulse felt and patient is a DNR."

During an interview with a Certified Nursing Assistant (CNA/staff #62) conducted on December 7, 2023 at 10:08 AM, the CNA stated that if there is a vital sign that looks too high or low, she will tell the nurse right away. She stated that they used a sheet that they grab every day and has section for blood pressure, respiration, .... and incontinent, and once the sheet is filled out with vital signs, she makes a copy and gives it to the nurse like for instance if she is done with room 78, she goes to the printer and make a copy and gives it to the nurse. The nurse has a copy by 7:00 AM and at the latest probably 7:30 AM. If low or high, she will retakes it again with same blood pressure cuff, and she will let the nurse know, and then the nurse will tell her to take with a manual blood pressure cuff just to make sure it is accurate reading. The vital signs that she takes are temperature, pulse, respiration, blood pressure and oxygen. Therapy does the height and weight.

An interview was conducted on December 7, 2023 at 10:20 AM with a Licensed Nursing Assistant (LNA/Staff #92). Staff #92 stated that LNA is same thing as CNA with fingerprint. She stated that she takes vital signs right away, and writes/put it all in the sheet and then enters it in the system. If too high or too low, She stated that sometimes she rechecks it and sometimes the nurses do it. By 6:30 or 7:00 AM, the vital signs are entered in the system.

Another interview was conducted on December 7, 2023 at 10:30 AM with a Licensed Practical Nurse (LPN/Staff #48). Staff #48 stated that admission nurses handles new patient, and then she gets report from them. The CNAs takes vital signs first thing in the morning before medication pass and the CNA gives us a copy of the paper of the residents' vital signs. Full set of vital signs are given to the nurse. She stated that she will go ask what happen if one of the vital signs is missing. Most part, the CNAs are pretty much on top of taking vital signs. Then, she stated that she will take the blood pressure for follow up, if they could not get it. Most part, the CNA will let me know if its high or low. If high or low, she will recheck it first, double check, then check what orders are in place, then she will let the provider know.

An interview was conducted with the Director of Nursing (DON/Staff #170) on December 7, 2023 at 10:50 AM. The DON stated that the process for rehab patient is we get their vital signs every day and as needed. If there is a bad vital sign, the CNA notifies the nurse. It depends on the vital signs, usually the nurse or the CNA retakes them. If it is a high blood pressure, the nurse will check if there is a medication ordered and then the nurse will give the medication. If there is a new onset, then they are to notify the provider. Sometimes the provider will say, thanks for letting me know with no new orders or might order. If there is no new order, we might get vital signs the next shift to make sure nothing is significantly chang

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that changes in resident #491 condition will be communicated to the physician.

Findings include:

Resident #491 was admitted on September 7, 2023, with diagnoses of traumatic hemorrhage of cerebrum without loss of consciousness, wedge compression fracture of T11-T12 vertebra, fracture of the lower end of right radius and lower end of right ulna, dementia, essential primary hypertension, and atrial fibrillation.

Record review dated September 8, 2023, revealed the following orders: aspirin 81 mg give one tablet by mouth one time a day for CVA prophylaxis, Lisinopril oral tablet 2.5 mg give one tablet by mouth one time a day for hypertension, and Amiodarone HCL oral tablet 200 mg give two tablets by mouth every 12 hours for atrial fibrillation for 7 days then give one tablet by mouth one time a day for atrial fibrillation for 23 days.

Record review dated September 8, 2023, revealed resident had a hypertension care plan with a goal to remain free of complication related to hypertension. The interventions included to give anti hypertensive medications as ordered, to monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness, to monitor for and document any edema and notify MD, to monitor/document abnormalities for urinary output and report significant changes to the MD, to monitor/document/report to MD as needed any signs and symptoms of malignant hypertension such as headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (Dyspnea), and to monitor/record medication side effects and report to MD as necessary.

On September 11, 2023, Interdisciplinary Team (IDT)-Brief Interview for Mental Status (BIMS) record revealed resident score was 0.0, a severe cognitive impairment.

The Minimum Data Set (MDS) dated September 13, 2023 revealed resident have a memory problem for short- and long-term memory; resident cognitive skills for daily decision making is severely impaired; resident required extensive assistance for bed mobility, transfer, dressing, eating, toilet use, personal hygiene; and resident required total dependence for bathing.

During the review of vital signs, record review revealed the resident had a systolic blood pressure that ranges from 112 millimeter of mercury to 168 millimeters of mercury, and a diastolic blood pressure ranges from 68 millimeter of mercury to 89 millimeters of mercury since admission. And on September 17, 2023 at 07:29, record revealed the resident had a one-time episode of a blood pressure of 168/110.

A physician progress note dated September 17, 2023 at 10:20 AM revealed, Patient lying in bed and no apparent distress. Seeing at around 9:50 AM. Not as talkative today. Appears comfortable. Blood Pressure: 168/110 September 17, 2023 at 7:29 AM. History of atrial fibrillation-on Amiodarone. On aspirin. Remains sinus on auscultation. Occasionally has an extra beat but remains in sinus. Follow up with cardiology. Hypertension-BP elevated. Monitor - on Lisinopril.

During the review of vital signs, record review revealed the resident had a pulse rate that ranges from 54 beats per minute regular rate to 98 beats per minute regular rate since admission. But on September 18, 2023 at 6:36 AM, record revealed the resident had a new onset irregular pulse rate of 115 beats per minute.

During the review of vital signs, record review revealed the resident had a respiration rate that ranges from 16 breaths per minute to 22 breaths per minute since admission. On September 18, 2023 at 6:36 AM, record revealed the resident had respiration of 26 breaths per minute.

There was no evidence found in the clinical record that the resident's physician was notified of the resident's blood pressure reading of 168/110 on September 17, 2023 at 7:29 AM. There was no evidence found in the clinical record that the resident physician was notified of the resident's new onset irregular heart rate of 115 beats per minute on September 18, 2023 at 6:36 AM, and there was no evidence in the clinical record that the resident's physician was notified regarding resident's status on September 18, 2023 "upon entering the patient's room this morning during shift report the patient was seen breathing heavily, ADON was called into the room. Oxygen saturation were reading at 97%. Frequent checks were provided to the patient and the daughter was called and left a voice message."

Record review revealed on September 18, 2023 at 8:20 AM, "therapy and CNA walked in the room and the patient was seen unresponsive, no pulse felt and patient is a DNR."

During an interview with a Certified Nursing Assistant (CNA/staff #62) conducted on December 7, 2023 at 10:08 AM, the CNA stated that if there is a vital sign that looks too high or low, she will tell the nurse right away. She stated that they used a sheet that they grab every day and has section for blood pressure, respiration, .... and incontinent, and once the sheet is filled out with vital signs, she makes a copy and gives it to the nurse like for instance if she is done with room 78, she goes to the printer and make a copy and gives it to the nurse. The nurse has a copy by 7:00 AM and at the latest probably 7:30 AM. If low or high, she will retakes it again with same blood pressure cuff, and she will let the nurse know, and then the nurse will tell her to take with a manual blood pressure cuff just to make sure it is accurate reading. The vital signs that she takes are temperature, pulse, respiration, blood pressure and oxygen. Therapy does the height and weight.

An interview was conducted on December 7, 2023 at 10:20 AM with a Licensed Nursing Assistant (LNA/Staff #92). Staff #92 stated that LNA is same thing as CNA with fingerprint. She stated that she takes vital signs right away, and writes/put it all in the sheet and then enters it in the system. If too high or too low, She stated that sometimes she rechecks it and sometimes the nurses do it. By 6:30 or 7:00 AM, the vital signs are entered in the system.

Another interview was conducted on December 7, 2023 at 10:30 AM with a Licensed Practical Nurse (LPN/Staff #48). Staff #48 stated that admission nurses handles new patient, and then she gets report from them. The CNAs takes vital signs first thing in the morning before medication pass and the CNA gives us a copy of the paper of the residents' vital signs. Full set of vital signs are given to the nurse. She stated that she will go ask what happen if one of the vital signs is missing. Most part, the CNAs are pretty much on top of taking vital signs. Then, she stated that she will take the blood pressure for follow up, if they could not get it. Most part, the CNA will let me know if its high or low. If high or low, she will recheck it first, double check, then check what orders are in place, then she will let the provider know.

An interview was conducted with the Director of Nursing (DON/Staff #170) on December 7, 2023 at 10:50 AM. The DON stated that the process for rehab patient is we get their vital signs every day and as needed. If there is a bad vital sign, the CNA notifies the nurse. It depends on the vital signs, usually the nurse or the CNA retakes them. If it is a high blood pressure, the nurse will check if there is a medication ordered and then the nurse will give the medication. If there is a new onset, then they are to notify the provider. Sometimes the provider will say, thanks for letting me know with no new orders or might order. If there is no new order, we might get vital signs the next shift to make sure nothing is significantly change. If on change of condition documentation, then vital signs are taken