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Based on interviews, record review, and facility policy review, it was determined the Governing Body failed to ensure the facility was adequately governed to ensure that patients received quality care and were protected from neglect. The facility failed to ensure there was an adequate number of nursing staff to provide care for the number and acuity of patients, and failed to ensure the facility had an effective Quality Assurance Performance Improvement (QAPI) program that identified and addressed quality of care at the facility.

Physician #1, who cared for Patient #1 when the patient was transferred to an acute care hospital on 09/26/17, stated Patient #1 endured "months of neglect" at the facility. Patient #1 expired on 09/28/17. (Refer to C0241, C0250, C0253, C0330, C0336, C0350, and C0383.)

Based on interviews, record review, and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. Record reviews and interviews revealed one (1) of ten (10) patients (Patient #1) was neglected. The Governing Body failed to ensure that the facility's policies and procedures prohibiting neglect were implemented and that Patient #1 was protected from neglect; failed to ensure there was an adequate number of nursing staff to provide care for the number and acuity of patients at the facility; and failed to ensure the facility had an effective Quality Assurance/Performance Improvement (QAPI) program that identified and addressed quality of care at the facility. (Refer to C0240, C0250, C0253, C0330, C0336, C0350, and C0383.)

The findings include:

Review of Patient #1's medical record revealed the facility admitted the patient on 10/20/16, with a diagnosis of anoxic brain injury. Upon admission, Patient #1 had a tracheostomy (a tracheotomy/tracheostomy is an opening surgically created through the neck into the trachea, or windpipe, to allow direct access to the breathing tube) and was on a ventilator, had an indwelling urinary catheter, and had a feeding tube. Patient #1 had no pressure ulcers/wounds upon admission to the facility. The facility failed to provide care related to the patient's catheter, feeding tube, and tracheostomy in accordance with physician orders and facility policy. The facility failed to accurately assess Patient #1's skin/pressure ulcers, failed to treat the patient's known pressure ulcers in accordance with physician's orders, and failed to ensure other existing pressure ulcers were identified and treated. According to staff, there was not enough staff at the facility to provide care patients required. Patient #1 developed multiple pressure ulcers, including pressure sores under the tracheostomy collar; the patient's urinary catheter and feeding tube leaked resulting in excoriation to the patient's skin; and the patient sustained a thirty-six (36) pound weight loss that the facility failed to identify and address.

Patient #1 was transferred to an acute care hospital on 09/26/17. Upon arrival, the acute care hospital identified that the patient had been "neglected" and notified the appropriate state agencies. The acute care hospital assessed Patient #1 to have a leaking/infected J-tube site, the indwelling urinary catheter appeared to have not been "properly maintained" and the patient had a urinary tract infection, the inner cannula of the tracheostomy had not been maintained properly and had to be changed and the patient had open pressure ulcers under the tracheostomy, the patient had multiple areas of skin breakdown (some of which had not been identified and treated by the facility), and Patient #1 had gram negative bacteremia (the presence of bacteria in the blood). The acute care hospital also documented that Patient #1 appeared very scared and frightened.

Interviews with Physicians #1 and #2, who treated Patient #1 at the acute care hospital, revealed Patient #1 had endured "months of neglect" at the facility. Interview with staff and the patient's family revealed they were never notified of the patient's deteriorating condition or involved in decisions about the patient's care. The family stated when Physician #1 contacted them from the hospital and explained the patient's condition, it was a "big surprise" and they were in "disbelief." Due to the patient's condition and poor prognosis, Patient #1's family decided to remove the patient from the ventilator. The patient expired on 09/28/17.

Interview with the Assistant Administrator and the Administrator on 10/17/17 at 1:50 PM, revealed they were in charge of the day to day operation of the facility and answered to the Board of Directors, who were the facility's governing body. The Administrator stated the Board of Directors reviewed policies and procedures on an annual basis; however, there was no evidence the Governing Body identified that the facility did not have policies/procedures to address assessing patients' skin, assessing pressure ulcers or wounds, or providing wound or pressure ulcer treatment or care of feeding tubes or indwelling urinary catheters. The Administrative staff stated the Governing Body reviewed and approved Medical Bylaws and Rules and Regulations on a bi-annual basis. The Administrator stated the hospital had a Chief of Staff and a Medical Executive Committee; however, they did not conduct peer review or routinely review medical records for quality of care. He stated that if there was a complaint the medical record was reviewed by an outside entity; however, there had been no complaints. The Administrative staff stated they were aware that there was a nursing staff shortage at the facility and were having a difficult time hiring nursing staff. They stated at no time had any staff member verbalized to them that they felt patients were unsafe or were neglected because of lack of staff. The Administrator stated he was aware that up until this incident the facility's QAPI program had identified no quality of care issues to report to the Governing Body.

Based on interview, record review, review of the facility's policies and procedures, and review of the nursing schedules, it was determined the facility failed to provide sufficient staff to ensure care was provided for one (1) of ten (10) sampled patients (Patient #1) in accordance with physician orders and facility policies. The facility failed to provide treatments related to Patient #1's tracheostomy, feeding tube, indwelling urinary catheter, and pressure ulcers in accordance with physician orders and facility policy. Interviews with facility staff revealed there was not enough nursing staff to provide care to patients at the facility.

The facility transferred Patient #1 to an acute care hospital on 09/26/17, because the patient's feeding tube was leaking. However, the acute care hospital's physician identified that the patient had been "neglected." Patient #1 presented to the acute care hospital with a leaking/infected feeding tube site with raw excoriation (skin has worn off) around the feeding tube that extended down the left side of the abdomen. The indwelling urinary catheter appeared to have not been "properly maintained," the patient had severe excoriation to the inner and back of the thighs with partial thickness skin loss (involves the first two layers of skin), and had a urinary tract infection. The inner cannula of the patient's tracheostomy had not been "properly maintained" and the patient had open pressure ulcers under the tracheostomy. The physician also noted that the patient had multiple areas of unidentified and untreated skin breakdown and gram negative bacteremia (the presence of bacteria in the blood). The patient's family decided to remove the patient from the ventilator (a machine designed to move breathable air into and out of the lungs) on 09/28/17. Patient #1 expired on 09/28/17. (Refer to C0240, C0241, C0253, C0330, C0336, C0350, and C0383.)

Based on interview, record review, review of the facility's policies and procedures, and review of the nursing schedules, it was determined the facility failed to provide sufficient staff to ensure care was provided for one (1) of ten (10) sampled patients (Patient #1) in accordance with physician orders and facility policies. The facility failed to provide treatments related to Patient #1's tracheostomy, feeding tube, indwelling urinary catheter, and pressure ulcers. On 09/26/17 at approximately 10:55 AM, Patient #1 was transferred to an acute care hospital for treatment where it was determined the patient's feeding tube was leaking "bilious contents" (bile contents) that resulted in skin breakdown and the patient's indwelling urinary catheter and the inner cannula of the tracheostomy had not been "properly maintained." Patient #1 was also assessed to have multiple areas of skin breakdown/pressure ulcers, some of which had not been identified or treated by the facility. Interviews with facility staff revealed there was not enough nursing staff to provide care to patients at the facility. (Refer to C0240, C0241, C0250, C0330, C0336, C0350, and C0383.)

The findings include:

The facility did not have a policy that addressed adequate staffing. Interview with the Director of Nursing (DON) on 10/11/17 at 3:30 PM, revealed the facility did not have a "written policy" for staffing; however, the requirement was for the facility to be staffed with five (5) licensed nursing staff and five (5) CNAs (certified nursing assistants) for day shift (7:00 AM to 7:00 PM). The DON stated night shift (7:00 PM to 7:00 AM) required five (5) nurses and three (3) CNAs.

1. Review of Patient #1's physician orders and treatment records for August and September 2017 revealed staff were required to assess and cleanse the skin around the patient's tracheostomy collar every shift (three times daily). However, further review revealed assessment and cleansing of Patient #1's tracheostomy was not completed approximately 20 of 93 times in August 2017, and the treatment was not provided approximately 27 of 76 times in September 2017.

Further review of a physician's order dated 07/14/17 revealed an order for Bactroban (antibiotic) ointment and a dry dressing to the area under and to the right of the patient's tracheostomy device daily. However, there was no documented evidence the treatments were provided in the month of August 2017.

2. Review of Patient #1's August and September 2017 treatment records revealed staff were required to cleanse the feeding tube site with soap and water and apply a dressing daily and as needed. Staff were also required to apply Ilex paste (a skin protectant paste that provides a topical skin barrier designed to protect the skin from breakdown while helping to soothe and heal damaged skin) to the feeding tube site as needed. Review of the treatment records revealed although Patient #1's abdomen was excoriated (layers of skin worn off), there was no documented evidence staff applied the Ilex paste in August, and only applied the Ilex paste five (5) times in September 2017. Further review of the treatment records revealed no documented evidence Patient #1's feeding tube site was cleansed as ordered 6 of 31 times in August 2017, and 6 of 25 times in September 2017.

3. Review of Patient #1's treatment record for August and September 2017 revealed the patient required indwelling urinary catheter care every shift (three times daily). However, review of the treatment record revealed no documented evidence catheter care was provided 21 of 93 times in August 2017, and 27 of 51 times in September 2017.

4. Review of Patient #1's skin assessment dated 09/25/17 revealed the facility assessed the patient to have a 4 x 3 centimeter (cm) pressure ulcer to the back of the left knee and a 3.5 cm by 1 cm pressure ulcer to the left calf. Review of Patient #1's physician's orders revealed an order to treat the pressure areas with a DuoDerm dressing; however, there was no documented evidence the facility provided the treatment from 09/01/17 through 09/12/17.

Further review of Patient #1's physician orders for September 2017 revealed orders to treat Patient #1's buttocks/sacrum with Ilex paste twice daily and to cover the sacrum with an "Allevyn" (type of wound dressing) dressing daily and as needed. However, review of the September 2017 treatment record revealed the facility did not provide the physician ordered treatment 13 of 51 times in September 2017. In addition, there was a physician's order to treat a Stage 2 pressure ulcer to the left buttock and the right inner buttock with a "DuoDerm" (clear wound dressing) dressing. Review of Patient #1's treatment record revealed that despite the physician's order there was no documented evidence the DuoDerm dressing was provided in September 2017.

Review of the nursing schedule for August 2017 and September 2017 revealed the facility failed to ensure the required number of nursing staff was scheduled and providing care to meet the patient's required needs for thirty-one (31) days in August and twenty-six (26) days in September. Continued review of the August and September 2017 schedule revealed the facility maintained a census of at least twenty (20) patients, of which a minimum of fifteen (15) patients were totally dependent upon staff for all care needs.

Interview with Certified Nursing Assistant (CNA) #2 on 10/10/17 at 12:56 AM, revealed when she came to work on 09/26/17 at 7:00 AM, Patient #1 was wet with urine and the patient's gown and blankets were saturated with leakage from the feeding tube. CNA #2 stated on numerous occasions she found patients wet and care had not been completed. Continued interview revealed she could not provide all the required patient care due to the lack of staff in the facility.

Interviews with CNA #1 on 10/10/17 at 11:30 AM, CNA #3 on 10/10/17 at 1:33 PM, Licensed Practical Nurse (LPN) #1 on 10/10/17 at 1:50 PM, LPN #2 on 10/10/17 at 2:26 PM, LPN #3 on 10/11/17 at 1:40 PM, Registered Nurse (RN) #3 on 10/09/17 at 2:45 PM, RN #5 on 10/11/17 at 12:04 PM, and RN #6 on 10/11/17 at 1:20 PM, revealed the patient acuity (intense care needs) at the facility was high and patients often required one nurse for every two (2) patients. Staff stated patients were often on ventilators (a machine designed to move breathable air into and out of the lungs), were receiving dialysis, had multiple pressure ulcers, and required total care. Further interviews with staff revealed the facility was very short-staffed and there was not enough staff to provide all the care the patients required. Staff stated they tried to ensure medications were given and the most basic needs of the patients were met. The staff stated in the last two (2) months, it was common to only have one (1) CNA on night shift who was assigned to care for twenty-five (25) patients. The nursing staff stated on numerous occasions they had found patients wet (soiled with urine) and care not provided. The nursing staff stated they had notified Administrative staff, and they (administrative staff) were aware that there was not enough staff to provide adequate/quality care for the acuity of the patients at the facility.

Interview with the Director of Nursing (DON) on 10/11/17 at 3:30 PM, revealed she was aware there were staffing issues at the facility. The DON stated the facility was actively recruiting to fill all open positions in Nursing, but it was difficult to recruit and retain staff. She stated the facility was utilizing agency nurses.

The facility transferred Patient #1 to an acute care hospital on 09/26/17 because the patient's feeding tube was leaking. However, the acute care hospital's physician identified that the patient had been "neglected" and had a leaking/infected feeding tube site with raw excoriation around the feeding tube that extended down the left side of the abdomen. The patient's indwelling urinary catheter appeared to have not been maintained and the patient had severe excoriation to the inner and back of his/her thighs with partial thickness skin loss (involves the first two layers of skin). The inner cannula of the tracheostomy had not been maintained properly; the patient had open pressure ulcers under the tracheostomy, and multiple areas of unidentified and untreated skin breakdown, a urinary tract infection, and had gram negative bacteremia (the presence of bacteria in the blood). The hospital also documented that Patient #1 appeared very scared and frightened. Patient #1's family decided to remove the patient from the ventilator (a machine designed to move breathable air into and out of the lungs) on 09/28/17, and the patient expired.

Based on observation, interview, and facility policy review, it was determined the facility failed to have an effective system for controlling infections and communicable diseases for two (2) of ten (10) sampled patients (Patient #5 and Patient #6). Observation of indwelling urinary catheter and tracheostomy care revealed staff failed to wash their hands and change gloves, and failed to properly contain soiled linen after providing care.

The findings include:

Review of the facility's "Infection Control Plan," not dated, revealed the objectives and goals of the department were to improve compliance with hand hygiene and infection control performance. Review of the facility's policy titled "Tracheostomy Care and Maintenance," dated 06/12/12, revealed when providing tracheostomy care, sterile technique would be followed.

Interview with the Director of Nursing (DON)on 10/17/17 at 10:30 AM, revealed the facility did not have a policy/procedure regarding care of patients' catheters.

1. Review of the medical record for Patient #6 revealed the patient was admitted to the facility on 10/03/17 with diagnoses including Respiratory Failure, and was ventilator (a machine that mechanically moves air into and out of the lungs for a patient who is physically unable to breathe, or breathing insufficiently) dependent.

Observation on 10/10/17 at 10:15 AM revealed Registered Nurse (RN) #8 and Certified Nursing Assistant (CNA) #3 were observed to provide indwelling catheter care for Patient #6. Observation revealed after completing catheter care, RN #8 carried the soiled, wet washcloths which had been utilized to perform catheter care, across the room. Water from the soiled washcloths was dripping onto the floor of Patient #6's room.

Further observation revealed RN #8 then gathered sterile tracheostomy supplies to be utilized to perform tracheostomy care for Patient #6, wearing the same soiled gloves she had utilized to perform catheter care. RN #8 placed the tracheostomy supplies on Patient #6's overbed table without cleaning the table or placing a protective barrier on the table surface. RN #8 then proceeded to perform tracheostomy site care for Patient #6, wearing the same soiled gloves she had utilized to perform indwelling catheter care. In addition, CNA #3 was observed to remove her soiled gloves she had worn while assisting RN #8 with indwelling catheter care for Patient #6, but failed to wash her hands after removal of the gloves and prior to repositioning Patient #6.

Interview with RN #8 on 10/16/17 at 2:35 PM, revealed she had been trained as a nurse to perform hand washing before and after any direct patient contact and between patient procedures. RN #8 stated she should have washed her hands and changed gloves between indwelling catheter care and tracheostomy care for Patient #6. RN #8 stated she was not aware what the facility's policy was for these procedures and was not sure what was to be utilized at the bedside for soiled linen. RN #8 stated she could not remember ever having been trained related to infection control at the facility.

2. Review of the medical record for Patient #5 revealed the patient was admitted to the facility on 06/01/17, with diagnoses including Dehydration, Renal Failure, and Sepsis.

Observation on 10/10/17 at 11:05 AM, revealed LPN #3 and CNA #3 provided indwelling urinary catheter care for Patient #5. After completing catheter care, CNA #3 transported the soiled, wet washcloths which had been utilized to perform the catheter care across the room, dripping the soiled liquid from the washcloths onto the floor of Patient #5's room. CNA #3 was then observed to place the soiled washcloths on the surface of the sink in Patient #5's room. LPN #3 and CNA #3 were then observed to reposition Patient #5 and apply ointment to the patient's sacral area without changing their gloves or performing hand hygiene.

Interview with LPN #3 on 10/10/17 at 11:30 AM, revealed LPN #3 was aware that soiled linens should be placed in a receptacle at the patient's bedside. The LPN further stated that surfaces that contacted soiled linen should be appropriately cleaned and sanitized. LPN #3 stated she had been trained on performing handwashing and indwelling catheter care, but could not recall when. She stated she "just forgot" to obtain a receptacle to place the soiled linens in at bedside.

Interview with CNA #3 on 10/16/17 at 2:15 PM, revealed she should have washed her hands and changed gloves prior to providing wound care. CNA #3 also stated she should have utilized a receptacle at the patient's bedside to place the soiled washcloths in and soiled linens should not have been placed on the sink's surface. CNA #3 stated she had not received training within the last year related to infection control including proper handwashing and the proper use of gloves.

Interview with the Infection Control Nurse on 10/11/17 at 1:40 PM, revealed she provided training related to handwashing and infection control to newly hired employees and provides additional training during the year. The Infection Control Nurse stated she provided training on infection control at least annually with the staff; however, there was no process in place to ensure each of the staff received the training. The Infection Control nurse stated she only worked at the facility part-time, and was unable to monitor staff to ensure appropriate infection control techniques were being utilized.

Interview with the Director of Nursing (DON) on 10/16/17 at 3:00 PM, revealed she expected nursing staff to follow infection control policies in regards to hand washing, universal precautions, and facility procedures. The DON stated she was not aware of any concerns related to infection control or handwashing procedures in the facility and had not observed any problems. However, the DON stated she did not routinely monitor staff for adherence to infection control techniques.

Based on interviews, record reviews, and review of facility policies, it was determined the facility failed to have an effective quality assurance program to evaluate the quality of patient care and treatment outcomes. Review of the facility's performance improvement plan revealed efforts would be made to monitor and evaluate the quality of patient care received in the facility and efforts would be made to assure that patient care was provided and maintained at an optimal level. However, interviews with staff and review of Quality Assurance Performance Improvement (QAPI) minutes revealed the facility failed to have a system in place to identify quality deficiencies. Interviews revealed they had never identified any concerns in the facility. (Refer to C0240, C0241, C0250, C0253, C0336, C0350, and C0383.)

Based on interviews, record reviews, and review of facility policies it was determined the facility failed to have an effective quality assurance program to evaluate the quality and appropriateness of care and treatment outcomes.

Review of the facility's performance improvement plan revealed efforts would be made to monitor and evaluate the quality of patient care received and efforts would be made to assure that patient care was provided and maintained at an optimal level. However, interviews with staff and review of Quality Assurance/Performance Improvement (QAPI) minutes revealed the facility failed to have a system in place to identify quality deficiencies, and staff stated they had never identified any concerns in the facility. (Refer to C0240, C0241, C0250, C0253, C0330, C0350, and C0383.)

The findings include:

Review of the facility's "Organizational Performance Improvement Plan," with an approval date of 12/29/16, revealed the purpose of the facility's Organizational Performance Improvement Plan was to ensure that the Governing Body, Medical Staff, and professional service staff demonstrated a consistent endeavor to deliver an optimal and consistent level of care in an environment of minimal risk. The plan also stated that the facility attempted to assure that the organization's resources were utilized in the most effective and efficient manner without sacrificing the quality of care and services provided. The plan further stated efforts would be made to maintain a comprehensive, effective system for monitoring and evaluating the quality of patient care and services provided throughout the organization. The policy also stated efforts would be made to assure that patient care was provided and maintained at an optimal level consistent with professional standards held in the medical community. In addition, the plan stated the facility would assure compliance with the requirements of all federal, state, and accrediting agencies in regard to quality assurance and performance improvement activities.

Review of a Hospital Surveyor Medical Record Review Tool for open and closed records, undated, revealed staff was required to review medical records to ensure the following documentation was included in the patient's medical record: informed consent; advance directives; assessment of physical, psychological, and social status; history and physical, pain assessment; conclusion or impressions drawn from the medical history and physical examination; the reason for admission or treatment; and a nutritional and functional screening was completed within 24 hours and when warranted. However, there was no evidence the facility had a system in place to monitor to ensure patients were receiving appropriate care and services based on their assessed care needs and clinical status.

The facility admitted Patient #1 on 10/26/16. Review of the patient's medical record revealed upon admission the patient had a feeding tube, an indwelling urinary catheter, and a tracheostomy (a tracheostomy or tracheostomy is an opening surgically created through the neck into the tracheostomy, or windpipe, to allow direct access to the breathing tube) with no concerns noted to the medical devices. According to Patient #1's admission/transfer documentation on 10/20/16, the patient had no pressure ulcers or skin breakdown upon admission. However, review of Patient #1's medical record and interviews with staff revealed the facility failed to provide tracheostomy care, indwelling urinary catheter care, and feeding tube care in accordance with physician orders and facility policy. Staff failed to provide treatment to pressure ulcers and failed to identify and treat all skin breakdown/pressure ulcers. Patient #1 sustained a thirty-six (36) pound weight loss in approximately three (3) months before the facility transferred the patient to an acute care hospital on 09/26/17. The transfer was related to the patient's feeding tube leaking.

Review of Patient #1's acute care hospital record revealed upon admission on 09/26/17, the patient had a leaking/infected feeding tube, and the site was noted with raw excoriation around the feeding tube that extended down the left side of the abdomen; the indwelling urinary catheter appeared to have not been maintained and the patient had severe excoriation to the inner and back of the thighs with partial thickness skin loss (involves the first two layers of skin). The inner cannula of the tracheostomy had not been maintained properly and the patient had open pressure ulcers under the tracheostomy. Further review revealed the patient had multiple areas of unidentified and untreated skin breakdown, a urinary tract infection, and had gram negative bacteremia (the presence of bacteria in the blood). Patient #1's family decided to remove the patient from the ventilator on 09/28/17, and the patient expired.

Interview on 10/11/17 at 8:21 AM, with Physician #1, the acute care hospital physician, revealed Patient #1 was in "terrible shape" when the patient arrived at the acute care hospital on 09/26/17. Physician #1 stated Patient #1 had "endured months of neglect" at the facility. The patient's feeding tube was leaking bilious (bile) contents, which resulted in skin breakdown. The physician also stated the facility had been withholding nutrition from Patient #1. According to Physician #1, Patient #1 was not a surgical candidate for a new feeding tube due to the patient's compromised clinical condition. Physician #1 stated Physician #3 should have had continuous conversations with Patient #1's family regarding the patient's condition and prognosis. Physician #1 stated he contacted Patient #1's family and explained the patient's poor prognosis and the patient's family elected palliative (comfort measures) care for the patient.

Interview with the hospital's palliative care physician, Physician #2, on 10/11/17 at 8:41 AM, revealed if the facility physician's plan of care included providing all life-sustaining measures possible, Patient #1 still had the right to receive nutrition, turning, and repositioning to prevent pressure sores, be kept clean and dry, and receive quality treatment. The physician stated the treatment Patient #1 was receiving at the facility was not the standard of care.

Review of the Quality Improvement Committee Meeting Minutes dated 08/15/17 revealed the Director of Nursing (DON) was charged with presenting information related to nursing services that was provided in the facility. However, there was no documented evidence the DON presented information to the Committee related to the provision, assessment, or monitoring of patient care.

Interview with the Executive Director of Medical Records and the Health Information Manager (HIM) on 10/17/17 at 10:00 AM, revealed nursing staff was responsible for conducting chart reviews every 24 hours to ensure physicians' orders were being implemented. However, the staff stated the results of the chart reviews and any identified concerns were not communicated in facility's Quality Assurance/Performance Improvement (QAPI) meetings.

Interview with the DON on 10/17/17 at 10:30 AM, revealed she only monitored to ensure patients' weights were obtained and lab orders were completed; she did not monitor to ensure any weight loss sustained by a patient was identified and appropriately addressed. The DON stated she did not monitor to ensure patient care was provided in accordance with physician orders and she did not ensure accurate assessments of patients' skin and pressure ulcers/wounds were being conducted. The DON stated she did not have the time to conduct chart reviews. She stated she was not aware that nursing documentation was as "substandard" as what was noted in Patient #1's medical record.

Interview with the QAPI Director on 10/17/17 at 9:00 AM, revealed the QAPI Committee met quarterly; however, the Committee had never identified a concern in the facility that warranted action by the QAPI Committee. The QAPI Director stated the Committee was not aware of any concerns or problems in the facility until the State Survey Agency presented concerns to facility staff.

Based on interviews, record review, and review of the facility's policies, it was determined the facility failed to ensure one (1) of ten (10) sampled patients (Patient #1) was free from neglect. Patient #1 was admitted to the facility on 10/20/16, from an acute care hospital. Upon admission to the facility, Patient #1 had a feeding tube, an indwelling urinary catheter, and a tracheostomy (a tracheostomy is an opening surgically created through the neck into the trachea, or windpipe, to allow direct access to the breathing tube) with no concerns noted to the feeding tube, indwelling urinary catheter, or tracheostomy upon admission. Patient #1 had no pressure ulcers or wounds upon admission to the facility. Review of Patient #1's medical record revealed after admission the patient developed chronic leakage from the feeding tube and indwelling urinary catheter that resulted in excoriation to the patient's abdomen and thighs. Patient #1 became nutritionally compromised and lost thirty-six (36) pounds as a result of the feeding tube leakage and receiving no nutrition. The patient developed numerous areas of skin breakdown and pressure ulcers including areas under the patient's tracheostomy.

Patient #1 was transferred to an acute care hospital on 09/26/17. Upon arrival to the hospital, Patient #1 was assessed to have a leaking/infected feeding tube site, the indwelling urinary catheter appeared to have not been "properly maintained" and the patient had a urinary tract infection, the inner cannula of the tracheostomy had to be changed because it had not been "properly maintained," and the patient had open pressure ulcers under the tracheostomy. Patient #1 had multiple areas of skin breakdown, and gram negative bacteremia (the presence of bacteria in the blood). The hospital also documented that Patient #1 appeared very scared and frightened. Physician #1 stated Patient #1 had endured "months of neglect." Physician #2 contacted Patient #1's family and discussed the patient's poor prognosis and the option of providing Patient #1 with comfort care. Patient #1's family was agreeable and the hospital removed Patient #1 from the ventilator on 09/28/17. Patient #1 expired on 09/28/17, with family at his/her bedside. (Refer to C0240, C0241, C0250, C0253, C0330, C0336, and C0383.)

Based on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to ensure one (1) of ten (10) sampled patients (Patient #1) was free from neglect. The facility admitted Patient #1 on 10/20/16, with a diagnosis of anoxic brain injury. Patient #1 had a feeding tube, an indwelling urinary catheter, and a tracheostomy (a tracheostomy is an opening surgically created through the neck into the trachea, or windpipe, to allow direct access to the breathing tube) with no concerns noted to the feeding tube, urinary catheter, or tracheostomy upon admission.

Review of Patient #1's admission/transfer documentation dated 10/20/16, revealed the patient had no pressure ulcers or skin breakdown. Record review and interview revealed the facility failed to provide tracheostomy care, indwelling urinary catheter care, jejunostomy tube (J-tube) care (jejunostomy tube is a soft, plastic feeding tube placed through the skin of the abdomen into the midsection of the small intestine; the tube is used to deliver food and medication to the patient). The facility also failed to ensure the patient received appropriate care to prevent and treat skin breakdown/pressure ulcers.

Patient #1 was transferred to an acute care hospital on 09/26/17. Upon arrival to the acute care hospital, the physician immediately recognized the patient had endured "months of neglect" and the appropriate State agencies were notified. The acute care hospital assessed Patient #1 to have a leaking/infected feeding tube site with excoriation around the side and the patient's abdomen; the indwelling urinary catheter appeared to have not been "properly maintained" and the patient had a urinary tract infection, the inner cannula of the tracheostomy had not been "properly maintained" and the patient had open pressure ulcers under the tracheostomy collar; the patient had multiple areas of skin breakdown and gram negative bacteremia (the presence of bacteria in the blood). The acute care hospital also documented that Patient #1 appeared very scared and frightened. Physician #1 and Physician #2 contacted Patient #1's family and discussed the patient's poor prognosis and the option of providing Patient #1 with comfort care. Patient #1's family was agreeable and the acute care hospital removed Patient #1 from the ventilator on 09/28/17. Patient #1 expired on 09/28/17, with family at his/her bedside. (Refer to C0240, C0241, C0250, C0253, C0330, C0336, and C0350.)

The findings include:

Review of the facility's Abuse Policy, undated revealed that all patients had the right to be free of practices and omissions and neglect that, left unchecked, would lead to abuse. Further review of the policy revealed neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. This presumed that instances of abuse of all patients, even those in a coma, caused physical harm, or pain or mental anguish.

1. Review of Patient #1's admission assessment dated 10/20/16, revealed the patient was admitted with chronic respiratory failure and was ventilator (a machine designed to move breathable air into and out of the lungs) dependent. Patient #1 had a #6 "Dick Shiley" (type of trach tube) tracheostomy that was patent and intact.

Review of the facility's tracheostomy policy, dated 06/12/12, revealed staff were required to provide stoma (an opening into the trachea) care every shift and as needed. The inner cannula (main body that is inserted into the tracheostomy) of the tracheostomy was required to be changed weekly and as needed.

Review of Patient #1's physician orders and treatment records for August and September 2017 revealed staff were required to assess and cleanse the skin around the tracheostomy collar every shift (three times daily). However, further review revealed the assessment and cleansing of Patient #1's tracheostomy was not completed approximately 20 of 93 times in August 2017; and the treatment was not provided approximately 27 of 76 times in September 2017.

In addition, further review of physician orders and treatment records revealed no documented evidence the inner cannula for Patient #1's tracheostomy was ever cleansed and/or changed as required by the facility's policy.

Review of a physician's order dated 07/14/17, revealed an order for Bactroban (antibiotic) ointment and a dry dressing to the area under and to the right of the patient's tracheostomy device daily. Review of the skin/wound assessments revealed no documented evidence the areas had been assessed or documented. There was no documented evidence the treatments were provided in the month of August 2017.

Further review revealed on 08/29/17, there was a physician's order to apply Bacitracin (antibiotic) to an open area under the tracheostomy daily. On 09/24/17, the physician changed the wound care orders for the tracheostomy site secondary to excoriation (redness, skin loss). There was no documented evidence the staff assessed the areas or documented the characteristics of the wounds.

Interview with Registered Nurse (RN) #5 on 10/11/17 at 12:04 PM, and RN #6 on 10/11/17 at 1:20 PM, revealed nursing staff cleaned around the patient's tracheostomy stoma; however, respiratory staff provided all tracheostomy care. RN #5 and RN #6 stated they were not aware of the type of tracheostomy Patient #1 had or when the last time the patient's inner cannula had been changed. However, review of the clinical record revealed the type of tracheostomy was documented in the patient's admission assessment.

Interview with Registered Respiratory Therapist (RRT) #2, the Respiratory Department Director, on 10/16/17 at 2:40 PM revealed he was aware Patient #1 had a "Shiley" tracheostomy. He stated the inner cannulas were required to be changed at least every 24-48 hours. RRT #2 stated when the inner cannula was cleansed/changed, it should be documented in the patient's medical record.

Interview with Registered Respiratory Therapist #1 on 10/16/17 at 12:05 PM, revealed Patient #1 had a "Shiley" tracheostomy and the inner cannula was checked twice daily and changed as needed, but RRT #1 did not document when the inner cannula was checked/changed and stated he did not know the last time the patient's inner cannula was changed.

Interview with RN #2 on 10/09/17 at 2:07 PM, revealed she was assigned to provide care for Patient #1 on 09/26/17, before the patient was transferred to the acute care hospital. RN #2 stated she was aware the patient had a "place" under the tracheostomy; however, she did not remove the dressing on 09/26/17, to provide the physician ordered treatment before the patient was transferred to another hospital.

Patient #1 was transferred to an acute care hospital on 09/26/17. Review of the Final Report from the acute care hospital revealed when Patient #1 arrived the acute care hospital had to change the patient's inner cannula of the tracheostomy due to the cannula not being properly maintained at the facility. The acute care hospital also found that the patient had copious secretions in the tracheostomy tubing and open pressure wounds under the tracheostomy.

2(a). Interview with the Director of Nursing on 10/17/17 at 10:30 AM, revealed the facility did not have a policy regarding care for feeding tubes.

Review of Patient #1's admission assessment dated 10/20/17, revealed the patient was admitted to the facility with a feeding tube. The patient's abdomen was soft and non-tender, the feeding tube site was within "normal limits," the tube flushed without difficulty, and there were no signs or symptoms of inflammation or drainage noted.

Review of a Certification and Consent to Transfer revealed on 11/11/16, and 04/28/17, the facility transferred Patient #1 for an evaluation to replace the feeding tube due to leakage from the feeding tube; however, there was no documented evidence that further attempts were made to address the patient's malfunctioning feeding tube.

Review of Nursing Notes dated 08/01/17 to 09/26/17, revealed the patient's feeding tube site was draining/leaking. At numerous times, staff documented that the patient's feeding tube was leaking moderate to large amounts of drainage described as yellow stool from the insertion site. Further review revealed the area around the feeding tube required frequent dressing changes due to the amount of drainage. On 09/12/17, a preliminary radiology report revealed after "an hour or so," the leakage around the patient's feeding tube site was saturating the dressing. On 09/25/17, staff placed an ostomy system on the feeding tube site "to attempt to record severity of drainage."

Further review of Nursing Notes dated 09/01/17 to 09/16/17, revealed nurses documented that the patient's abdomen was red with areas of skin breakdown and bleeding. However, review of the wound assessments dated 09/13/17, 09/19/17, and 09/25/17 and the Nursing Notes revealed no documented evidence the facility assessed the feeding tube site or the abdominal area of the patient.

Review of Patient #1's August and September 2017 treatment records revealed staff was required to cleanse the feeding tube site with soap and water and apply a dressing daily and as needed. Staff was also required to apply Ilex paste (a skin protectant paste that provides a topical skin barrier designed to protect the skin from breakdown while helping to soothe and heal damaged skin) to the feeding tube site as needed. Review of the treatment records revealed that although record review revealed Patient #1's abdomen was excoriated, there was no evidence staff applied the Ilex paste in August and only applied the Ilex paste five (5) times in September 2017. Further review of the treatment records revealed no documented evidence that Patient #1's feeding tube site was cleaned as ordered 6 of 31 times in August 2017, and 6 of 25 times in September 2017.

Interview with Registered Nurse (RN) #5 on 10/11/17 at 12:04 PM, revealed she had found Patient #1's bed linens/gown saturated with drainage from the patient's feeding tube and was concerned with the patient's worsening skin condition. RN #5 stated the patient's feeding tube was "dry rotting" and had "popped" open at one point when she attempted to administer the patient's medication. However, there was no documented evidence the nurse notified the patient's physician. RN #5 stated she decided to cut off the area of the feeding tube that had popped open and moved the port further down the tube. In addition, there was no documented evidence that the alteration to the feeding tube was made or that the feeding tube was assessed after the alteration was made by RN #5.

Interview with RN #2 on 10/09/17 at 2:07 PM, revealed the patient's skin was in "pretty bad shape" because the patient's feeding tube was leaking.

Interview with Licensed Practical Nurse (LPN) #2 on 10/10/17 at 2:26 PM, revealed Patient #1's feeding tube "leaked horribly" and the patient's skin integrity had "gotten worse" due to leakage and poor nutrition.

Interview with Certified Nursing Assistant (CNA) #2 on 10/10/17 at 12:56 PM, revealed on the morning of 09/26/17, Patient #1's gown and blankets were saturated with leakage from the feeding tube.

2(b). Review of the facility's weight policy, undated, revealed patients would remain within five (5) percent of their usual body weight. The policy stated unintentional weight loss (loss of 2% in one week, 5% in one month, or 8% in three months) would be prevented. The policy stated if a patient sustained unintentional weight loss, a nutritional assessment would be completed and the patient's prognosis, medical plan (curative or maintenance), advance directives, and the "best feeding route" would be considered.

Continued review of Patient #1's medical record revealed physician orders for Glucerna 1.5 continuous feeding at 40 milliliters per hour (ml/hr) with water flushes at 40 ml/hr.

Review of Patient #1's nursing notes revealed staff stopped the patient's feeding on 09/03-09/17, because the tube feeding was running out the feeding tube insertion site. On 09/05/17, the feeding was noted to be flowing from the tube and contained "chunks." Further review of nursing notes revealed on 09/14/17, the patient's medication and water flushes were documented as coming out of the feeding tube site and running down the patient's abdomen.

Review of Patient #1's weight record revealed from 07/01/17 to 09/24/17, the patient lost 36.2 pounds. The patient weighed 198.2 pounds on 07/01/17 and weighed 162 pounds on 09/24/17.

Review of Nutritional Progress Notes dated 08/04/17, revealed Patient #1 lost six pounds from 07/22-29/17 (weight was 189.6); lost 5.6 pounds from 07/29-08/05/17 (weight was 184); lost 5.7 pounds from 08/05-12/17 (weight was 178.2); lost 4.6 pounds from 08/12-19/17 (weight was 173.6); lost 2.8 pounds from 08/19-26/17 (weight was 170.8). The dietitian documented each time that the patient was having no nausea/vomiting or residual tube feeding (refers to the volume of fluid/feeding remaining in the stomach at a point in time during tube feeding). The dietitian indicated she would "continue to monitor weights"; however, there was no documented evidence the dietitian acted upon Patient #1's continued weight loss.

Further review of Nutritional Progress Notes revealed Patient #1's weight was not obtained on 09/03/17 or 09/10/17, and the patient's feeding tube site was leaking at a "large rate." The dietitian documented the patient's condition was discussed with Nursing and was supposed to be discussed with the physician; however, there was no documented evidence the patient's weight loss was ever discussed with the patient's physician.

Continued review of Patient #1's Nutritional Progress Notes revealed the dietitian documented on 09/14/17, that the patient lost another 7.85 pounds from 08/19/17 to 09/12/17. On 09/22/17, the dietitian documented that the patient lost one pound from 09/12/17 to 09/17/17 (weight was 164.8), and the patient's feeding tube continued to leak. On 09/25/17, the dietitian documented the patient lost 2.8 pounds the previous week (weight was 162) and the patient's tube feeding was held that night secondary to increased residuals; however, there was never any documented evidence the dietitian acted upon the patient's weight loss, made any recommendations to address the weight loss, or discussed the weight loss with the patient's physician.

Interview with RN #5 on 10/11/17 at 12:04 PM revealed Patient #1's feeding tube contents leaked from the feeding tube and staff was concerned that the patient's physician was holding the patient's nutrition.

Interview with LPN #1 on 10/10/17 at 1:50 PM, revealed Patient #1's feeding tube leaked "profusely" and she frequently reported the leakage to Physician #3. LPN #1 stated the physician's only treatment was to hold the patient's tube feeding.

Interview with LPN #2 on 10/10/17 at 2:26 PM, revealed Patient #1's feeding tube "leaked horribly" and the only treatment was to hold the feedings. LPN #1 stated she was aware the patient had lost weight and she did not feel comfortable holding the resident's feedings all the time. LPN #2 stated she had reported her concerns to Physician #3.

An interview with Physician #3 on 10/11/17 at 10:15 AM, and on 10/17/17 at 12:00 PM revealed he was aware the patient's feeding tube was leaking a "high volume." Physician #3 stated he was aware the patient had excoriation to the abdomen due to stomach contents leaking from the feeding tube. However, he stated he did not order a treatment for the excoriation because it was "not a wound." Further interview with Physician #3 revealed he was aware the patient's feeding tube appeared to be "dry rotting" and "disintegrating." Physician #3 stated he was not aware the patient lost 36 pounds. He stated that nursing staff had reported concerns about the patient's feeding tube leaking and nutrition when he held the feedings. Physician #3 stated that is why he transferred the patient to an acute care hospital on 09/26/17.

Interview with the dietitian on 10/16/17 at 3:00 PM, revealed she was required to assess Patient #1 routinely because the patient received tube feeding. The dietitian stated she was not aware the patient sustained a thirty-six (36) pound weight loss in three (3) months, even though she documented the weekly weight loss. Further interview revealed she was not aware the patient's tube feedings were turned off for prolonged periods of time. She stated had she been aware she could have suggested supplements, alternative artificial feeding, and would have monitored the patient more closely.

Review of the acute care hospital medical record dated 09/26/17, revealed Patient #1 presented to the acute care hospital with continuous leakage from the feeding tube and skin breakdown secondary to "bilious" (bile, which is acidic) drainage onto the skin. The feeding tube site was assessed to be raw, with excoriation around the feeding tube site extending down the left side of the abdomen. The acute care hospital record further revealed the patient was nutritionally compromised as a result of the malfunctioning feeding tube.

Interview with the acute care hospital admitting physician, Physician #1, on 10/12/17 at 8:21 AM, revealed Patient #1 was in "terrible shape" due to "months of neglect" at the facility. The patient's feeding tube was leaking bilious contents, which had resulted in skin breakdown. The physician also stated the facility had been withholding nutrition from Patient #1. According to Physician #1, Patient #1 was not a surgical candidate for a new feeding tube due to the patient's compromised clinical condition.

Interview with the acute care hospital palliative care physician, Physician #2, on 10/11/17 at 8:41 AM, revealed if the facility physician's plan of care included providing all life sustaining measures possible, Patient #1 still had the right to receive nutrition, turning and repositioning to prevent pressure sores, to be kept clean and dry, and receive quality treatment. The physician stated the treatment Patient #1 was receiving at the facility was not the standard of care.

3. Interview with the Director of Nursing on 10/17/17 at 10:30 AM, revealed the facility did not have a policy/procedure regarding care of patients' catheters.

Review of Patient #1's Admission Assessment dated 10/20/17, revealed the patient had an indwelling urinary catheter to obtain accurate urinary output. The assessment revealed the catheter was patent and properly placed.

Review of Patient #1's treatment record for August and September 2017 revealed the patient required catheter care every shift (three times daily). However, review of the treatment record revealed no documented evidence catheter care was provided 21 of 93 times in August 2017 and 27 of 51 times in September 2017. In addition, there was no documentation the patient's catheter leaked or that the patient had any skin breakdown due to a leaking catheter.

Review of a transfer form for Patient #1 revealed the patient was transferred to an acute care hospital on 09/26/17.

Review of Patient #1's acute care hospital record revealed acute care hospital staff documented that the patient's urinary catheter appeared to have not been "properly maintained." The patient had a urinary tract infection and bacteremia (blood infection). The patient had severe excoriation to the inner thighs and the back of the left thigh. The areas were "raw" with "partial thickness skin loss." Acute care hospital nurses reported that the patient was wet with urine upon arrival, despite having a urinary catheter in place.

Interview with Licensed Practical Nurse (LPN) #2 on 10/10/17 at 2:26 PM, revealed Patient #1's urinary catheter leaked continuously which, according to the LPN, negated the purpose of the catheter.

Interview with Certified Nursing Assistant (CNA) #2 on 10/10/17 at 12:56 PM, revealed upon her arrival to work on 09/26/17 at 7:00 AM, Patient #1 had been left wet with urine for an unknown amount of time. CNA #2 stated the patient's catheter continuously leaked and staff had to provide frequent incontinence care to keep the patient dry.

Interview with CNA #1 on 10/10/17 at 11:30 AM, revealed she often came to work and found patients soiled with urine.

Interview with Physician #3 on 10/17/17 at 12:00 PM, revealed he was not aware what the facility's standard of practice was for catheter care. Physician #3 stated he was aware the patient's urinary catheter was continuously leaking, but he was not aware the patient had excoriation.

Interview with Physician #1 on 10/11/17 at 8:21 AM, revealed when Patient #1 arrived at the acute care hospital, the patient's urinary catheter was leaking "horribly." The physician stated he "could not understand" why the catheter remained inserted due to the continuous leakage.

4. Review of the facility's skin care policy, undated, revealed the policy did not address assessing patients' skin, assessing pressure ulcers or wounds, or providing wound or pressure ulcer treatment.

Review of Patient #1's medical record revealed the patient was admitted to the facility on 10/20/16. Review of Patient #1's Discharge Summary revealed when the patient was transferred to the facility, the patient had no wounds/pressure ulcers.

Review of Patient #1's skin assessment dated 09/25/17 revealed the facility assessed the patient to have a 4 x 3 centimeter (cm) pressure ulcer to the back of the left knee and a 3.5 x 1 cm pressure ulcer to the left calf. Review of a wound assessment dated 09/25/17 revealed the facility assessed the area to the back of the left knee as a Stage 2 pressure ulcer that was red and draining with foul odor ("date of occurrence unknown"). However, the wound assessment did not address the pressure ulcer to the left calf. Further review of Patient #1's physician's orders revealed an order to treat the pressure areas with a DuoDerm dressing; however, there was no documented evidence the facility provided the treatment from 09/01/17 through 09/12/17.

Record review revealed Patient #1 was transferred to an acute care hospital on 09/26/17, where the acute care hospital assessed the area to the left calf as unstageable and was covered with soft, black eschar (dead tissue) with foul smelling, "puslike" discharge. There were areas of the wound margin that were loosely adherent and when probed were undermining (fat and muscle [deep tissue] damage) at those points. The wound assessment revealed the wound would require surgical debridement if comfort measures were not chosen. The acute care hospital wound assessment revealed Patient #1 had scattered Stage 2 and shallow full thickness Stage 3 wounds to the sides and backs of both legs that had not been identified by the facility.

Further review of Patient #1's Physician Orders for September 2017 revealed orders to treat Patient #1's buttocks/sacrum with Ilex paste twice daily and to cover the sacrum with an Allevyn dressing daily and as needed. There was no documented evidence the facility assessed the sacrum and buttocks and documented why the treatment was being provided. Further review of the September 2017 treatment record revealed the facility did not provide the physician ordered treatment 13 of 51 times in September 2017. In addition, there was a physician's order to treat a Stage 2 pressure ulcer to the left buttock and the right inner buttock with a DuoDerm dressing. Again, there was no evidence the patient's buttocks were assessed or documentation made regarding what was being treated. Review of Patient #1's treatment record revealed despite the physician's order, there was no documented evidence the DuoDerm dressing was provided in September 2017. A skin assessment completed when Patient #1 was transferred to the acute care hospital on 09/26/17, revealed the patient had full thickness wounds (the wound extended below all layers of the skin into the layer that contains fat and tissue that contains blood vessels and nerves) to the left buttock and trochanter (hip).

Review of a skin assessment dated 09/25/17, revealed the facility assessed Patient #1 to have a 1 cm thick x 1 cm wide (no depth documented) pressure sore to the coccyx. However, according to a skin assessment completed at an acute care hospital on 09/26/17, the pressure ulcer to the coccyx was a full thickness wound.

Further review of the acute care hospital's skin assessment dated 09/26/17, revealed the acute care hospital identified and assessed that Patient #1 had a deep tissue injury to the right heel (a deep tissue injury is a purple or maroon discoloration due to damage of underlying soft tissue from pressure and/or shear) and dark unstageable areas over most bony prominences of the feet. There was no documented evidence the facility identified and assessed these areas.

Interview with Registered Nurse (RN) #3 on 10/09/17 at 2:45 PM, revealed if treatments were not documented in the Nursing Notes or on a treatment record, the treatment was not provided.

Interview with Licensed Practical Nurse (LPN) #2 on 10/10/17 at 2:26 PM, revealed she had reported to work and found that staff had not provided the required care for patients' wounds. LPN #2 further stated Patient #1's skin had declined.

Interview with RN #5 on 10/11/17 at 12:04 PM, revealed staff was concerned about Patient #1's condition, including the patient's skin. The RN stated they reported the patient's condition to the physician often; however, she was unaware what action to take when she felt Physician #1 did not respond to her concerns.

Interview with the Wound Care Nurse, RN #1, on 10/09/17 at 11:00 AM, revealed she was required to assess and provide treatment to patients' wounds once per week. RN #1 stated on other days the patient's assigned nurse was responsible for assessments and treatments of wounds. She stated she had concerns that staff did not provide wound care as ordered. RN #1 stated she recalled on an unknown date that she changed Patient #1's dressing on a Monday and documented the date on the dressing. She stated on the following Thursday, Patient #1's daily dressing had not been changed and the patient had the same dressing on from Monday.

Interview with Physician #1 on 10/11/17 at 8:21 AM revealed when Patient #1 arrived to the acute care hospital on 09/26/17, Patient #1's skin integrity was compromised and the patient had "endured months of neglect."

5. Review of the facility's policy titled "Patient Rights," undated, revealed patients had the right to receive support and protection of fundamental human, civil, and legal rights. Continued review of the policy revealed patients had the right to receive respect for the dignity of life from conception to natural death. Further review of the policy revealed patients had the right to be informed of realistic care alternatives when facility care was no longer appropriate.

Continued review of Patient #1's medical record revealed no documented evidence Patient #1's family was notified or kept informed of the patient's condition when the patient developed pressure ulcers, excoriation, leakage from the feeding tube and catheter, or sustained a significant weight loss.

Interview with Licensed Practical Nurse (LPN) #1 on 10/10/17 at 1:50 PM, LPN #2 on 10/10/17 at 2:26 PM, Registered Nurse (RN) #5 on 10/11/17 at 12:04 PM, and RN #6 on 10/11/17 at 1:20 PM, revealed Patient #1 often cried and grimaced and tears ran down the patient's face. Staff stated they administered pain medication when this occurred, but never notified the patient's family that the resident was tearful and required frequent pain medication. Further interview with the staff revealed they had never contacted Patient #1's family to involve them in decision-making for the patient and had never informed the patient's family of the patient's deteriorating condition.

Interview with Patient #1's attending physician, Physician #3, on 10/11/17 at 10:15 AM, revealed he had never contacted Patient #1's family regarding changes in orders or the patient's condition. Physician #3 stated Patient #1's family made the decision for the patient to receive life-prolonging measures upon admission and he did not see the need to discuss the patient's condition any further with the family, even when the patient's condition declined and changed significantly from admission. Physician #3 stated he "honored" some patient wishes for no cardiopulmonary resuscitation and comfort measures, but he did not "push those thoughts" because "that was up to a higher authority."

Interview with Physician #1, the acute care hospital physician, on 10/11/17 at 8:21 AM, revealed Patient #1 was in "terrible shape" when the patient arrived at the acute care hospital on 09/26/17. Physician #1 stated Patient #1 had "endured months of neglect" at the facility. Physician #1 stated Physician #3 should have had continuous conversations with Patient #1's family regarding the patient's condition and prognosis. Physician #1 stated he contacted Patient #1's family and explained the patient's poor prognosis and the patient's family elected palliative care for the patient.

Interview with Patient #1's family on 10/12/17 at 2:01 PM, revealed the facility only contacted the family on two (2) occasions, once to tell them they were going to administer blood to the patient and once to notify them they were transferring the patient to an acute care hospital. Patient #1's family stated they had no idea the patient had lost weight, the patient's feeding tube was leaking, or that the patient had multiple pressure ulcers/wounds. The family stated when Physician #1 contacted them from the acute care hospital and explained the patient's condition, it was a "big surprise" and they were in "disbelief." The family member stated that after speaking with Physician #1, and learning of the patient's condition and prognosis, they made the decision to remove the patient from the ventilator.

Review of Patient #1's acute care hospital medical record revealed Patient #1 was removed from the ventilator on 09/28/17, and expired.