Downtown Brooklyn Nursing & Rehabilitation Center
June 13, 2017 Complaint Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 13, 2017
Corrected date: July 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during an abbreviated survey, the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. This was evidenced for 1of 3 residents sampled for Quality of Care/Treatment (Resident #1). Specifically, Resident # 1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Date Set dated 12/19/2015 identified Resident #1 with active [DIAGNOSES REDACTED]. The facility did not developed a care plan to address the diagnosis. Complaint # 4 The findings include: Resident #1 was an 88-year female initially admitted to the facility 07/03/2014 with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified the resident with long/short-term memory impairments. A review of Resident #1's active Comprehensive Care Plans (CCP) from 2014 to 03/2017 had no documented evidence that an individualized CCP was developed for Resident #1's [DIAGNOSES REDACTED]. A subsequent telephone interview was conducted on 03/30/2017 at 12:36PM, with the Director of Nursing Service (DNS). She stated that she did not see any CCP on [MEDICAL CONDITION]. She further stated that she saw a CCP on orthostatic Blood Pressure and that staff could have incorporated [MEDICAL CONDITION] and collapse on the same CCP. The DNS was ask who is responsible for developing the CCPs, she stated that the Registered Nurses (RN) are responsible for initiating the CCPs and the Licensed Practical Nurses update them. 415.11(c)(1)

Plan of Correction: ApprovedJuly 6, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F279 Develop a Comprehensive Care Plan
Element 1
1. Resident #1 expired on [DATE]. The MDS Coordinator responsible for checking the care plans is no longer employed at the facility.
Element 2
1. MDS Assessor will audit 20% of all MDS OBRA submission to ensure care plan reflect all appropriate [DIAGNOSES REDACTED]. The findings will be reported to the Quality Management Committee for further recommendations. ( [DATE] & ongoing)
Element 3
1. Registered Nurses were educated on the policy for the Care Planning Process and the importance of developing, reviewing and revising care plans to ensure they reflect the appropriate [DIAGNOSES REDACTED].?s needs. All RNs will initiate and update care plans as needed. ([DATE] & ongoing)
2. The review of resident care plans will occur during the comprehensive care plan review and quarterly by the Interdisciplinary team to discuss any needed changes to the care plan based on the current assessment. ([DATE] & ongoing)
Element 4
1. MDS Assessor will audit 20% of all MDS OBRA submission to ensure care plan reflect all appropriate [DIAGNOSES REDACTED]. The findings will be reported to the Quality Management Committee for further recommendations. ( [DATE] & ongoing)
Element 5
1. MDS Assessor will audit all the Comprehensive care plans for new admissions to ensure care plans reflect all appropriate [DIAGNOSES REDACTED]. The findings will be reported to the Quality Management Committee for further recommendations. ([DATE] & ongoing)
2. The MDS Coordinator will be responsible for monitoring the process. ([DATE] & ongoing)
3. Findings will be reviewed quarterly at the Quality Management Committee for further recommendations. (QI Committee)

FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 13, 2017
Corrected date: June 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that a physician was immediately notified of a change in a resident medical condition. This was evidenced by 1 of 3 residents sampled for Quality of Care/Treatment (Resident #1). Specifically, Resident #1 reported that she vomited and was not feeling well. The RN did not assess Resident #1 and the RN did not notify Resident #1's physician. Subsequently, Resident #1 was observed unresponsive in the room. Cardiopulmonary Resuscitation (CPR) initiated, but was unsuccessful. The Emergency Medical Service pronounced Resident #1 on [DATE] at 1:19PM. Complaint # 4 The findings include: Resident #1 was an 88-year female initially admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified the resident with long/short-term memory impairments. A Licensed Practical Nurse (LPN) note dated [DATE] at 3:23PM documented that the Certified Nursing Assistant (CNA) called her to the resident room stating that the resident vomited. The resident verbalized to this writer that she vomited. I took her vital signs (VS) ,[DATE], 98.1, 72, 18. I asked the resident did she have any pain she stated no I just feel nauseous. I gave the resident a ginger ale and an emesis basin. I spoke with the resident for 20 minutes. The resident stated she felt better and I left the room. Daughter came to call director (RN) to the room and I followed her. We found the resident lying in bed unresponsive. CPR was started 911 was called. 911 reached facility at 1:10PM. Resident was pronounced at 1:19PM. CNA provided care and family remains at bedside. An RN note dated [DATE] at 3:34PM documented that Resident #1 expired at 1:20PM today. The doctor made aware and her daughter is present on the unit. Family still at bedside post mortem care to be provided and Resident #1's body to remove to holding. A review of Resident #1's medical record, revealed that the RN did not perform an assessment and the RN did not notify the doctor regarding Resident #1's complaints of not feeling well, vomiting, and nausea. On [DATE] at 2:18PM, the complainant was interviewed. She stated that she arrived at the facility at approximately 12:30PM and went to Resident #1's room. She observed Resident #1 lying in bed with her head facing the foot of the bed. She stated that as she was talking to Resident #1, she realized that Resident #1 was not responding. She also stated that she called Resident #1's name and Resident #1 did not respond or move. She stated that she ran to the dining room, grabbed the RN and they went back to Resident #1's room. She stated that the RN checked Resident #1's pulse stating that the pulse was weak. In addition, the complainant stated that a nurse verbalized to her that earlier in the day Resident #1 complained of not feeling good and that she threw up. She further stated that no one assessed Resident #1 after she complained of not feeling good. On [DATE] at 11:23AM, the CNA was interviewed. She stated that Resident #1 called her to the room stating that she vomited and that she did not feel good. She also stated Resident #1 stated that she flushed the vomitus down the toilet. She affirmed that she informed the LPN who was sitting at the nursing station. She also stated the LPN went in to see Resident #1. The CNA was asked approximately what time did Resident #1 complained of not feeling well and she stated, approximately 11:00AM before lunch. She added that the lunch was not on the unit when Resident #1 complained and when she informed the LPN. The CNA was asked about the time lunch arrived on the unit, and she stated, about 12:00PM or a little after 12:00PM. On [DATE] at 11:10AM, the LPN was interviewed. She stated, at approximately 12:00PM, the CNA came into the dining room and informed her that Resident #1 stated that she was not feeling well and that she had vomited. The LPN stated that she went to Resident #1's room took vital signs, and gave Resident #1 the emesis basin and a ginger ale as Resident #1 stated that she was nauseous. She also stated that she spoke with Resident #1 for approximately 20 minutes before leaving the room. She affirmed that she went to the nursing station where the RN was sitting and informed the RN that Resident #1 complained of not feeling well and that Resident #1 had vomited. She also informed the RN that she gave Resident #1 a ginger ale for the nausea. The LPN was asked about the RN's response, and she stated the RN replied, Ok. The LPN was asked what time did Resident #1's daughter come to the dining room to get the RN, and she stated, I am not sure; I believe it was about 15 minutes or more after I left the resident room. The LPN was asked if the doctor was informed and she stated that she notified the RN. She also stated that when they arrived in Resident #1's room, Resident #1 was unresponsive. She stated that she initiated CPR and that the RN called 911. She stated Resident #1 expired in the facility. On [DATE] at 11:00AM, the RN was interviewed. She stated that she was in the dining room, between 12:00PM and 12:30PM, when Resident #1's daughter came into the dining room on the unit, grabbed her by the hand stating, Come with me. She stated that the LPN was also in the dining room and followed them to Resident #1's room where Resident #1 was lying in bed unresponsive. The RN was asked if she had conducted an assessment of Resident #1 when the LPN informed her that Resident #1 was not feeling well and she stated, No, I did not assess Resident #1, the LPN told me after Resident #1 was observed unresponsive. She further stated the LPN initiated CPR and that she called 911 and Code Blue. She affirmed that EMS pronounced Resident #1 at 1:20PM. On [DATE] at 11:32AM, the Director of Nursing Service (DNS) was interviewed. She stated that she was informed of the code and she went to Resident #1's room where she observed CPR in progress. She further stated that she did not suspect anything was wrong until she was being interviewed. She affirmed that she was not aware that the RN did not assess Resident #1 and that the doctor was not informed when Resident #1 first complained of not feeling well. 483.10(b)(11)

Plan of Correction: ApprovedJuly 6, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F157 Notify of Changes:
Element 1
1. Resident #1 expired on [DATE]. The LPN who failed to notify the Physician of the change in condition has been counseled and re-educated on the policy for physician notification. (Completed [DATE])
2. The RN who failed to complete an assessment of the resident was also counseled and educated on the importance of completing an assessment when a resident experiences a change in condition. The RN is no longer working at the facility. (Completed [DATE])
Element 2
1. The 24-hour report for the last two weeks in (MONTH) was reviewed by the Nurse Managers to ensure the physician and responsible party was notified for any resident changes in condition ([DATE]).
2. Managers/Supervisors conducted visual observation on all units [DATE] to identify any immediate change in condition of current resident in house. No immediate concerns were identified. ( [DATE])
Element 3
1. The DNS reviewed the policies for Physician Notification and Significant Changes in Condition and no changes were needed in the notification process. ([DATE])
2. The staff educator/designee will re-educate all licensed nurses on the policy for Physician Notification and Significant Changes in Condition and the importance of timely assessment/observation and reporting of information to the medical provider and responsible party. ( [DATE] & ongoing)
Element 4
1. The DNS will review the 24 hour report to identify any changes in condition that required assessment and notification of physician and responsible party. The audit will be completed daily for four weeks and weekly for three months and then monthly thereafter. Findings will be reviewed at the quality Management Committee for further recommendations. ( [DATE] & ongoing)
Element 5
1. The DNS will review the 24 hour report to identify any changes in condition that required assessment and notification of physician and responsible party. The audit will be completed daily for four weeks and weekly for three months and then monthly thereafter. Findings will be reviewed at the quality Management Committee for further recommendations. ( [DATE] & ongoing)
2. The deficient practice will be monitored by the RN Unit Managers and reviewed by the Director of Nursing. ([DATE] & ongoing)
3. Findings will be reviewed quarterly at the Quality Management Committee for further recommendations. (QI Committee)

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 13, 2017
Corrected date: July 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that a resident received the necessary care and services required to maintain the highest practicable well-being. This was evidenced for 1 of 3 sampled residents (Resident #1). Specifically, Resident # 1 reported that she vomited and was not feeling well. The Licensed Practical Nurse (LPN) notified the Registered Nurse (RN) who did not performed an assessment and did not inform the doctor. Subsequently, Resident #1 was discovered unresponsive in the room. Cardiopulmonary Resuscitation (CPR) initiated, but was unsuccessful. The Emergency Medical Service pronounced Resident #1 on [DATE] at 1:19PM. Complaint # 4 The findings include: Resident #1 was an 88-year female initially admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified the resident with long/short-term memory impairments. A Licensed Practical Nurse (LPN) note dated [DATE] at 3:23PM documented that the Certified Nursing Assistant (CNA) called her to the resident room stating that the resident vomited. The resident verbalized to this writer that she vomited. I took her vital signs (VS) ,[DATE], 98.1, 72, 18. I asked the resident did she have any pain she stated no I just feel nauseous. I gave the resident a ginger ale and an emesis basin. I spoke with the resident for 20 minutes. The resident stated she felt better and I left the room. Daughter came to call director (RN) to the room and I followed her. We found the resident lying in bed unresponsive. CPR was started 911 was called. 911 reached facility at 1:10PM. Resident was pronounced at 1:19PM. CNA provided care and family remains at bedside. An RN note dated [DATE] at 3:34PM documented that Resident #1 expired at 1:20PM today. The doctor made aware and her daughter is present on the unit. Family still at bedside post mortem care to be provided and Resident #1's body to remove to holding. A review of Resident #1's medical record, revealed that the RN did not performed an assessment and the RN did not notify the doctor regarding Resident #1's complaints of not feeling well, vomiting, and nausea. On [DATE] at 2:18PM, the complainant was interviewed. She stated that she arrived at the facility at approximately 12:30PM and went to Resident #1's room. She observed Resident #1 lying in bed with her head facing the foot of the bed. She stated, as she was talking to Resident #1, she realized that Resident #1 was not responding. She also stated that she called Resident #1's name and Resident #1 did not respond or move. She stated that she ran to the dining room, grabbed the RN and they went back to Resident #1's room. She stated that the RN checked Resident #1's pulse stating that the pulse was weak. In addition, the complainant stated that a nurse verbalized to her that earlier in the day Resident #1 complained of not feeling good and that she threw up. She further stated that no one assessed Resident #1 after she complained of not feeling good. On [DATE] at 11:23AM, the CNA was interviewed. She stated that Resident #1 called her to the room stating that she vomited and that she did not feel good. She also stated Resident #1 stated that she flushed the vomitus down the toilet. She affirmed that she informed the LPN who was sitting at the nursing station and the LPN went in to see Resident #1. The CNA was asked approximately what time did Resident #1 complained of not feeling well and she stated, approximately 11:00AM before lunch. She added that the lunch was not on the unit when Resident #1 complained and when she informed the LPN. The CNA was asked what time lunch arrived on the unit, and she stated, About 12:00 or a little after 12:00. On [DATE] at 11:10AM, the LPN was interviewed. She stated, at approximately 12:00PM, the CNA came to the dining room and informed her that Resident #1, stated that she was not feeling well and that she had vomited. The LPN stated that she went to Resident #1's room took vital signs, and gave Resident #1 the emesis basin and a ginger ale as Resident #1 stated that she was nauseous. She also stated that she spoke with Resident #1 for approximately 20minutes before leaving the room. She affirmed that she went to the nursing station where the RN was sitting and informed the RN that Resident #1 complained of not feeling well and that she vomited. She also informed the RN that she gave Resident #1 a ginger ale for the nausea. The LPN was asked about the RN's response, and she stated the RN replied, Ok. The LPN was asked what time did Resident #1's daughter come to the dining room to get the RN, and she stated, I am not sure; I believe it was about 15 minutes or more after I left the resident room. The LPN was asked if the doctor was informed and she stated that she notified the RN. The LPN was asked approximately, what time did the lunch came to the unit and she stated approximately 12:10PM. She also stated, when they arrived in Resident #1's room, Resident #1 was unresponsive. She affirmed that she initiated CPR and that the RN called 911. She stated Resident #1 expired in the facility. On [DATE] at 11:00AM, the RN was interviewed. She stated that she was in the dining room, between 12:00PM and 12:30PM, when Resident #1's daughter came into the dining room on the unit, grabbed her by the hand stating, Come with me. She stated that the LPN was also in the dining room and followed them to Resident #1's room where Resident #1 was lying in bed unresponsive. The RN was asked if she had conducted an assessment of Resident #1 when the LPN informed her that Resident #1 was not feeling well and she stated, No, I did not assess Resident #1, the LPN told me after Resident #1 was observed unresponsive. She further stated the LPN initiated CPR and that she called 911 and Code Blue. She affirmed that the Emergency Medical Service (EMS) pronounced Resident #1 at 1:20PM. On [DATE] at 11:32AM, the Director of Nursing Service (DNS) was interviewed. She stated she was informed of the code, and that she went to Resident #1's room where CPR was in progress. She also started that the crash cart was at Resident #1's room door. She further stated that she did not suspect anything was wrong, until the interviewed. She affirmed that she was not aware that the RN did not assess Resident #1 and that the doctor was not informed when Resident #1 first complained of not feeling well. 415.11(c)(3)(i)

Plan of Correction: ApprovedJuly 6, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F309 Provides Care/Services for Highest Well Being

Element 1
1. Resident #1 expired on [DATE]. The LPN who failed to notify the RN and Physician of the change in condition has been counseled and re-educated on the policy for physician notification. (Completed)
2. The RN who failed to complete an assessment of the resident was also counseled and educated on the importance of completing an assessment when a resident experiences a change in condition. The RN no longer works for the facility. (Completed)
Element 2
1. The 24 hour report for last two weeks in (MONTH) was reviewed to ensure the physician and responsible party was notified for any resident changes in condition. No immediate concerns identified.
2. Managers/Supervisors conducted visual observation on all units [DATE] to identify any immediate change in condition of current resident in house. ( [DATE])
Element 3
1. The DNS reviewed the policies for Physician Notification and Significant Changes in Condition and were found to be compliant. ([DATE])
2. The staff educator/designee will educate all licensed nurses on the policy for Physician Notification and Significant Changes in Condition and the importance of timely assessment/observation and reporting of information to the medical provider and responsible party. ([DATE] & ongoing)

Element 4
1. The DNS will review the 24 hour report to identify any changes in condition that required assessment and notification of physician and responsible party. ([DATE] & ongoing)
2. The audit will be completed daily for four weeks and weekly for three months and then monthly thereafter. Findings will be reviewed at the quality Management Committee for further recommendations. ([DATE] & ongoing)
Element 5
1. The DNS will review the 24 hour report to identify any changes in condition that required assessment and notification of physician and responsible party. ([DATE] & ongoing)
2. The audit will be completed daily for four weeks and weekly for three months and then monthly thereafter. Findings will be reviewed at the quality Management Committee for further recommendations. ([DATE] & ongoing)
3. The deficient practice will be monitored by the RN Unit Managers and reviewed by the Director of Nursing. ([DATE] & ongoing)
4. Findings will be reviewed quarterly at the Quality Management Committee for further recommendations. (QI Committee)

FF10 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 13, 2017
Corrected date: June 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during an abbreviated survey, the facility did not ensure professional standards of quality were met. This was evidenced by 1 of 3 residents sampled for Quality of Care/Treatment (Resident #1). Specifically, Resident # 1 reported that she vomited and was not feeling well. The Registered Nurse (RN) did not assess Resident #1 and did not notify the physician. Subsequently, Resident #1 observed unresponsive in the room. Cardiopulmonary Resuscitation (CPR) initiated and Resident #1 expired in the facility. Complaint # 4 The findings include: Resident #1 was an 88-year female initially admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified the resident with long/short-term memory impairments. A Licensed Practical Nurse (LPN) note dated [DATE] at 3:23PM documented that the Certified Nursing Assistant (CNA) called her to the resident room stating that the resident vomited. The resident verbalized to this writer that she vomited. I took her vital signs (VS) ,[DATE], 98.1, 72, 18. I asked the resident did she have any pain she stated no I just feel nauseous. I gave the resident a ginger ale and an emesis basin. I spoke with the resident for 20 minutes. The resident stated she felt better and I left the room. Daughter came to call director (RN) to the room and I followed her. We found the resident lying in bed unresponsive. CPR was started 911 was called. 911 reached facility at 1:10PM. Resident was pronounced at 1:19PM. CNA provided care and family remains at bedside. An RN note dated [DATE] at 3:34PM documented that Resident #1 expired at 1:20PM today. The doctor made aware and her daughter is present on the unit. Family still at bedside post mortem care to be provided and Resident #1's body to remove to holding. A review of Resident #1's medical record, revealed that the RN did not performed an assessment and the RN did not notify the doctor regarding Resident #1's complaints of not feeling well, vomiting, and nausea. On [DATE] at 2:18PM, the complainant was interviewed. She stated that she arrived at the facility at approximately 12:30PM and went to Resident #1's room. She observed Resident #1 lying in bed with her head facing the foot of the bed. She stated that as she was talking to Resident #1, she realized that Resident #1 was not responding. She also stated that she called Resident #1's name and Resident #1 did not respond or move. She stated that she ran to the dining room, grabbed the RN and they went back to Resident #1's room. She stated that the RN checked Resident #1's pulse stating that the pulse was weak. In addition, the complainant stated that after everything was over, a nurse verbalized to her that earlier in the day Resident #1 complained of not feeling good and that she threw up. She further stated that no one assessed Resident #1 after she complained of not feeling good. On [DATE] at 11:23AM, the CNA was interviewed. She stated that Resident #1 called her to the room stating that she vomited and that she did not feel good. She also stated Resident #1 stated that she flushed the vomitus down the toilet. She affirmed that she informed the LPN who, was sitting at the nursing station and that the LPN went in to see Resident #1. The CNA was asked approximately what time did Resident #1 complained of not feeling well, and she stated, at approximately 11:00AM before lunch. She added that the lunch was not on the unit when Resident #1 complained and when she informed the LPN. The CNA was asked the time lunch arrived on the unit, and she stated, About 12:00PM or a little after 12:00PM. On [DATE] at 11:10AM, the LPN was interviewed. She stated, at approximately 12:00PM the CNA came to the dining room and informed her that Resident #1 stated that she was not feeling well and that she had vomited. The LPN stated she went to Resident #1's room, took her vital signs, and gave Resident #1 the emesis basin and a ginger ale as Resident #1 stated she was nauseous. She also stated she spoke with Resident #1 for approximately 20 minutes before leaving the room. She affirmed that she went to the nursing station where the RN was sitting and informed the RN that Resident #1 complained of not feeling well and that she vomited. She also informed the RN that she gave Resident #1 a ginger ale for the nausea. The LPN was asked about the RN's response, and she stated the RN replied, Ok. The LPN was asked what time did Resident #1's daughter come to the dining room to get the RN, and she stated, I am not sure; I believe it was about 15 minutes or more after I left the resident room. The LPN was ask if the doctor was informed and she stated she notified the RN. The LPN was asked approximately, what time did the lunch came to the unit and she stated approximately 12:10PM. She also stated that when they arrived in Resident #1's room, Resident #1 was unresponsive. She stated she initiated CPR and the RN called 911. She stated that Resident #1 expired in the facility. On [DATE] at 11:00AM, the RN was interviewed. She stated that she was in the dining room between 12:00PM and 12:30PM when Resident #1's daughter came into the dining room on the unit, grabbed her by the hand stating, Come with me. She also stated the LPN was in the dining room and followed them to Resident #1's room where Resident #1 was lying in bed unresponsive. The RN was asked if she had conducted an assessment of Resident #1 when the LPN informed her that Resident #1 was not feeling well and she stated, No, I did not assess Resident #1, the LPN told me after Resident #1 was observed unresponsive. She further stated the LPN initiated CPR and she called 911 and Code Blue. She affirmed that 911 pronounced Resident #1 at 1:20PM. On [DATE] at 11:32AM, the Director of Nursing Service (DNS) was interviewed. She stated she was informed of the code and she went to Resident #1's where she observed CPR in progress. She also stated the crash cart was at Resident #1's room door. She further stated she did not suspect anything was wrong until she was interviewed. She affirmed that she was not aware that the RN did not assess Resident #1 and that the doctor was not informed when Resident #1 first complained of not feeling well. 415.11(c)(3)(i)

Plan of Correction: ApprovedJuly 6, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F281 Services Provided Meet Professional Standards
Element 1
1. Resident #1 expired on [DATE]. The LPN who failed to notify the RN and Physician of the change in condition has been counseled and re-educated on the policy for physician notification. (completed)
2. The RN who failed to complete an assessment of the resident was also counseled and educated on the importance of completing an assessment when a resident experiences a change in condition. The RN no longer works for the facility. (Completed)
Element 2
1. The 24 hour report for last two weeks in (MONTH) was reviewed to ensure the physician and responsible party was notified for any resident changes in condition. No immediate concerns identified
2. Managers/Supervisors conducted visual observation on all units [DATE] to identify any immediate change in condition of current resident in house. ( [DATE])

Element 3
1. The DNS reviewed the policies for Physician Notification and Significant Changes in Condition and were found to be compliant. ([DATE])
2. The staff educator/designee will educate all licensed nurses on the policy for Physician Notification and Significant Changes in Condition and the importance of timely assessment/observation and reporting of information to the medical provider and responsible party. ([DATE] & ongoing)
Element 4
1. The DNS will review the 24 hour report to identify any changes in condition that required assessment and notification of physician and responsible party. ([DATE] & ongoing)
2. The audit will be completed daily for four weeks and weekly for three months and then monthly thereafter. Findings will be reviewed at the quality Management Committee for further recommendations. ([DATE] & ongoing)
Element 5
1. The DNS will review the 24 hour report to identify any changes in condition that required assessment and notification of physician and responsible party. ([DATE] & ongoing)
2. The audit will be completed daily for four weeks and weekly for three months and then monthly thereafter. Findings will be reviewed at the quality Management Committee for further recommendations. ([DATE] & ongoing)
3. The deficient practice will be monitored by the RN managers and reviewed by the Director of Nursing. ([DATE] & ongoing)
4. Findings will be reviewed quarterly at the quality Management Committee for further recommendations. (QI Committee)