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Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure its nursing staff supervised the care of two (2) of ten (10) sampled patients, Patient #1 and Patient #2.

Review of Patient #1's record and interview with the patient and facility staff revealed he/she was admitted with a post-operative surgical wound on 05/17/2022 which was covered with a dressing. Patient #1 was admitted to the facility for a five (5) day period, from 05/17/2022 through 05/21/2022. However, review revealed no documented evidence nursing staff assessed the Patient #1's surgical wound, contacted the physician to obtain orders to evaluate and/or provide necessary care of the wound to ensure it remained free from potential complications.

In addition, Patient #2 was admitted to the facility with no Pressure Ulcers (PU); however, he/she developed a PU to the coccyx after admission which required treatment. The facility failed to ensure additional necessary interventions for treatment of the PU which advanced to an unstageable PU.

The findings include:

Review of the facility policy titled, "Swing Beds: Conditions of Participation" approved on 11/24/2020, revealed the facility's Nursing Services were to ensure patients safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each patient as determined by the patient assessments and individual plans of care. Continued review of the policy revealed nursing services were to provide care, which included but was not limited to, assessing, evaluating, planning and implementing patient care plans and responding to the patient's individual needs. The policy review further revealed nursing staff were to complete a thorough assessment of each patient admitted to the unit to determine the patient's physical, mental and psychosocial condition at the time of admission.

1. Review of Patient #1's medical record revealed the facility admitted him/her on 05/17/2022, with diagnoses which included post-operative status for an Open Reduction with Internal Fixation (ORIF) due to a right humeral fracture (the long bone in the arm that runs from the shoulder to the elbow). Further review of the medical record revealed Patient #1's surgical procedure was conducted on 05/12/2022.

Review of Patient #1's admission nursing assessment revealed he/she was noted to have a skin impairment to his/her right shoulder due to a surgical incision and the dressing was clean and dry. Continued review of the assessment revealed no documented evidence nursing staff assessed Patient #1's surgical incision after he/she was admitted to the facility. Further review of Patient #1's medical record revealed no documented evidence nursing staff assessed his/her post-operative surgical site during his/her admission to the facility from 05/17/2022 through 05/21/2022, a period of five (5) days, to ensure the surgical site remained free from potential complications.

Interview with Licensed Practical Nurse (LPN) #1 on 05/27/2022 at 3:30 PM, revealed he admitted Patient #1 to the facility on 05/17/2022. He stated the patient arrived at the facility with no Physician's orders regarding the care and treatment of his/her surgical incision. Continued interview revealed he had not contacted the Physician for guidance on how to assess and care for the patient's incision but stated he should have done that. LPN #1 stated he had cared for the patient on a "few occasions" during his/her five (5) day stay at the facility. He further stated to his knowledge no one had obtained any Physician's orders nor had anyone removed the patient's dressing and assessed his/her surgical incision during his/her stay.

Interview with Registered Nurse (RN) #3, the Unit Facilitator, on 06/01/2022 at 1:40 PM, revealed she assisted LPN #1 with Patient #1's admission assessment as the RN on 05/17/2022. She stated it was the RN's responsibility to complete the new admission's initial body system assessments (lung sounds, cardiac sounds, etc). Continued interview revealed the RN was also responsible for completing any incision or wound assessments that were applicable to newly admitted patients at the facility. She stated she observed Patient #1's dressing on his/her right shoulder as clean, dry and intact at the time of his/her admission; however, she acknowledged not having assessed the actual surgical incision to ensure it was free from potential complications. Further interview revealed RN #3 had not felt she needed to contact the Physician "that soon" upon Patient #1's admission regarding how the surgical incision should have been cared for while he/she was at the facility.

Interview with the Interim Director (RN #4) of the Swing Bed/Acute Care Unit on 06/02/2022 at 1:25 PM, revealed when new admissions arrived at the facility the RN working with the LPN was responsible for ensuring the admission and necessary documentation were completed properly. The Director stated staff should have contacted the Physician and inquired about how often Patient #1's surgical dressing should have been removed, and how frequently nursing staff were expected to assess Patient #1's surgical site. Further interview revealed Patient #1's surgical incision should have been assessed for signs of infection during his/her stay at the facility to prevent complications.

Interview with RN #1 on 06/01/2022 at 9:30 PM revealed he had been trained to complete admissions at the facility. RN #1 stated if a patient was admitted to the facility with a surgical incision the nurse was responsible for contacting the Physician and obtaining orders so an initial assessment could be completed of the post-operative incision. Continued interview revealed patients having had surgical procedures performed at the facility's "sister" facility, frequently arrived at the facility with no orders regarding their surgical incision. Further interview revealed then staff had to contact the Physician(s) to ensure post-operative incisions were treated appropriately for healing and to prevent complications.

Interview with Surgeon #1 on 06/03/2022 at 12:00 PM, revealed he expected nursing staff would have contacted him on a Patient #1's admission to the facility and obtain the orders necessary for assessing and care for his/her surgical incision. The Surgeon stated if nursing staff would have contacted him, he would have ordered Patient #1's incision to be assessed daily and have dry dressing changes completed daily also. Further interview revealed he would have expected the facility's nursing staff to contact him with any questions or concerns regarding Patient #1's operative site.

Interview with the Chief Nursing Officer (CNO) on 06/09/2022 at 2:35 PM revealed she would not have expected staff to contact the Physician and obtain orders to remove Patient #1's dressing or to assess his/her surgical site on admission. She stated Physician orders were required for staff to remove the dressing and assess his/her surgical site. Further interview revealed however, she had no concerns regarding Patient #1 residing in the facility for five (5) days without nursing staff assessing or evaluating his/her surgical site to ensure it remained from potential complications.

Interview with the Chief Executive Officer (CEO) on 06/09/2022 at 2:40 PM, revealed he would have expected nursing staff to have contacted Patient #1's "provider" regarding what the expectations were regarding the care or treatment of his/her post-operative site when he/she was admitted to the facility. He further stated nursing staff should assess all wounds and surgical sites for patients who were admitted or resided in the facility to assist in ensuring the patients remained free from adverse complications.

2. Review of the facility policy titled, "Prevention and Treatment of Pressure Injuries" approved March 2021, revealed all patients were to be assessed for existing skin problems and the potential risk for developing pressure injuries. Per review, the primary care nurse was to notify the Healthcare Practitioner of pressure injuries upon initial observation and obtain an order for the Wound Ostomy Continence Nurse (WOCN) to evaluate and recommend treatment of the pressure injury. Continued review revealed pressure injuries present on admission were required to be documented and photographed within twenty-four (24) hours of the admission. Review revealed therapeutic pressure reduction mattress should be used in all inpatient care areas as a preventive and treatment measure. Per review, in the event of a facility acquired pressure injury or development of other new wounds, the Physician or WOCN should be notified and new orders initiated for evaluation and treatment of the new wounds.

Review of Patient #2's medical record revealed the facility admitted the patient from the Acute Care area to the Swing Bed unit on 01/07/2022, with diagnoses including Declining Functional Status, Dementia, Depression, Primary Hyperparathyroidism, Depression, and Acute Metabolic Encephalopathy. Review of Patient #2's RN Admission Assessment dated 01/07/2022, revealed the facility assessed the patient: as requiring limited assistance of two (2) staff members for bed mobility and bathing; had active range of motion in both sides of his/her upper and lower extremities; was incontinent of bowel and bladder; and had no Pressure Ulcers (PU) present. According to the assessment the patient had altered mental status with cognitive confusion, therefore no Brief Interview for Mental Status (BIMS) score assessment was conducted. Continued review revealed the facility discharged Patient #2 on 02/16/2022. Record review revealed Patient #2 was placed on the facility's admission protocol plan of care related to physical limitations, limited mobility, debility and incontinence.

Review of the admission protocol plan of care for Patient #2 revealed the facility care planned him/her for hourly rounding assessments, a turning schedule every two (2) hours, daily adult skin assessment for skin problems and the use of the Braden Scale Skin assessment tool. Review of the Braden Scale Skin assessment tool revealed the facility assessed Patient #2 as at low risk for developing Pressure Ulcers (PU).

Further medical record review revealed the facility initiated Patient #2's Long Term Care Plan (LTCP) reviewed/revised on 02/14/2022. Review of the LTCP revealed on 01/17/2022 staff determined Patient #2 had the potential for impaired skin integrity related to his/her diagnoses which included Acute Metabolic Encephalopathy, Sepsis, Urinary Tract Infection (UTI), Hypokalemia and Hypoxia. Review of LTCP interventions implemented by the facility for Patient #2 revealed staff were to: monitor skin care techniques; keep skin clean, dry and intact; avoid pressure on skin; avoiding sheering/friction; assess for redness over bony prominence's; assess capillary refill over reddened areas; evaluate need for specialty beds/mattresses; and assist resident in position changes as ordered. Further review of the LTCP revealed staff were also to monitor the patient's nutritional status and hydration status and monitor lab values and report abnormals to Physician.

Review of Patient #2's skin integrity assessment dated 01/07/202 (his/her admission date), revealed the patient had no PUs; however, his/her buttocks were pink and a skin barrier had been applied. Continued medical record review revealed the WOCN assessed Patient #2 on 01/10/2022 at 7:14 AM as per the facility's initial admission protocol. Review of the WOCN's 01/10/2022 documentation also revealed the WOCN made recommendation for skin barrier cream to continue to be applied to Patient #2's upper buttocks and noted no wound care was needed at that time.

Review of Patient #2's skin integrity assessment dated 01/15/2022, revealed staff identified a small, dime sized open area to his/her coccyx and a wound consult was placed. Review of the WOCN's assessment documentation dated 01/17/2022 at 11:19 AM assessment revealed Patient #2's medial coccyx had yellow serosanguineous (discharge that contains both blood and a clear yellow liquid) drainage, and "reddened erythematous" appearance to the surrounding tissue without odor. Record review revealed the WOCN took a photo of the wound on 01/17/2022, and staged the open area as unstageable (wound covered with slough or eschar). Continued review revealed the WOCN's measurements of Patient #2's coccyx wound were noted as; Length (L) 2.00 cm (centimeters) by Width (W) 2.00 cm, by Depth (D) 0.30 cm. Per review, the WOCN documented applying hydrophilic cream (a moisturizing cream to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) to the open area and covered the area with a plain foam dressing, and encouraged Patient #2 to turn every 2 (two) hours.

Review of Patient #2 Physician Orders dated 01/18/2022 revealed orders for hydrophilic cream to be applied to the patient's sacrum open area once daily and PRN (as needed) with incontinence; turn the patient every two (2) hours; and not place the patient on his/her sacrum which needed to remain "offloaded" (minimizing or removing weight placed on a body area to help prevent or heal ulcers). Review of the Physician Orders revealed an order initiated on 01/19/2022, for a Turn and Position System with Wedges (TAP) which was placed on Patient #2's care plan as an intervention.

Review of the WOCN assessment dated 01/24/2022 at 5:05 PM, revealed Patient #2's medial coccyx PU had yellow serosanguineous drainage and erythematous tissue appearance. Continued review of the WOCN's documentation for 01/24/2022 revealed the measurements of Patient #2's PU were noted as (L) 1.50 cm, by (W) 1.50 cm by (D) 0.20 cm with light exudate, slough tissue type. Further review revealed the WOCN's PU comments were noted as: "Wound appears to be smaller, yellow still noted in wound base. Recommend to continue hydrophilic cream and offloading".

Review of the WOCN assessment dated 02/02/2022 revealed the visit was for follow up and the WOCN noted Patient #2's "unstageable wound appears to be smaller, yellow slough still noted in wound base." Continued review of the 02/02/2022 WOCN documentation revealed the measurements of Patient #2's PU were (L) 1.00 cm, by (W) 1.00 cm, by (D) 0.20 cm with recommendations noted to continue the hydrophilic cream and offloading.

Review of the WOCN follow up skin assessment dated 02/07/2022, revealed Patient #2's medial coccyx wound appearance and measurements remained the same as from the previous WOCN visit. Continued review of the WOCN documentation dated 02/07/2022 revealed recommendations to cleanse Patient #2's medial coccyx wound with normal saline (NS), pat dry, and apply Thera-honey paste (a medical grade honey), and cover with a bordered foam dressing.

Review of the final WOCN follow up assessment dated 02/14/2022, revealed Patient #2's medial coccyx wound was noted to have yellow serosanguineous drainage and the WOCN had been unable to stage the wound. Further review revealed no measurements noted and a recommendation documented to continue the "Medi-Honey".

Review of Patient #2's care plan implemented on his/her admission on 01/07/2022, revealed the patient was to be placed on a every two (2) hour turning schedule. However, review of Patient #2's nursing daily assessment note documentation for the time period of 01/07/2022 through 02/15/2022, revealed nursing staff noted the patient as primarily lying on his/her back throughout his/her admission to the facility, with no documented evidence the patient was turned and repositioned, or implementation of further interventions. Per review of the nursing documentation Patient #2 nor his/her family had refused to have staff assist the patient with turning and repositioning. Review further revealed the facility failed to provide Patient #2 a therapeutic pressure reduction mattress as a preventive and treatment measure even though the facility's policy and procedure "Prevention and Treatment of Pressure Injuries" indicated that should be done.

Interview on 05/26/2022 at 2:00 PM, with Personal Care Technician (PCT) #1, revealed the PCTs were responsibilities for their patients included: turning and feeding their patients; obtaining their weights; providing their personal care needs; and assisting with all patient care needs. PCT #1 revealed the nurses responsibilities for patients included: assessments; monitoring of all care areas; and wound care and dressing changes. Per PCT #1, the facility's PCTs were also responsible for alerting the nurses regarding any concerns or skin issues with the patients. Further interview with PCT #1 revealed Patient #2 had been "pleasantly confused" throughout his/her stay at the facility, and was always trying to "get out of bed." PCT #1 further revealed Patient #2 refused to turn and pulled his/her wedge out from under him/her which staff used to keep the pressure off areas.

Interview on 06/02/2022 at 9:06 PM, with PCT #4 revealed he was responsible for providing the care and assistance all residents required or requested. PCT #4 revealed Patient #2 required "much" assistance, and would "play" in his/her feces. Continued interview revealed Patient #2 attempted to get out of bed and refused turning "quite frequently". PCT #4 further revealed the PCTs made the nurses aware of any patient refusal of care and of refusals to turn.

Interview on 06/06/2022 at 1:10 PM, with the facility's WOCN revealed she recalled providing care for Patient #2 related to a PU on his/her coccyx. The WOCN revealed if a patient was noncompliant the department initiated interventions to promote pressure relief and for offloading. Continued interview revealed the facility had a device that was plugged into the patients' mattress in order to create a low air loss and micro climate to allow air flow to prevent moisture. The WOCN revealed however, she could not remember the device which was to have been initiated for Patient #2. Per the WOCN, she had been aware of Patient #2's noncompliance with not turning and repositioning through the nursing assessment, the "alert board" and the Braden Scale Skin Assessment. Further interview revealed she did not know whose responsibility it was to initiate the additional air flow pressure relief device for patients' mattresses. The WOCN further revealed Patient #2 would have benefited from the extra support device and stated she suspected the patient had been on the device.

Interview on 06/07/2022 at 2:11 PM, with LPN #1 revealed he recalled caring for Patient #2 and recalled the patient refused turning and eating. He stated the nurses were aware of Patient #2's refusal to turn, not eating and of the wound on his/her coccyx. Per LPN #1, he was not aware of any specific staff who monitored care areas such as patients' weights, turning and repositioning, or of their nutrition. LPN #1 revealed there had been no additional air flow device on Patient #2's mattress; however, agreed extra interventions and precautions should have been put into place for Patient #2 including daily weights and Dietician monitoring.

Interview with RN #5 on 06/06/2022 at 5:55 PM, revealed the nurses were responsible for the total care and monitoring of all systems for patients residing on the facility's swing bed unit. RN #5 stated the nurses responsibility also included: looking at patients daily/weekly weights; their skin and wounds; the percentage of their meal/fluid intake and output per shift; and their past history and current medical diagnoses which all factored in to the monitoring of patients. She stated it was the nurses responsibility to notify the Physician, Registered Dietician (RD) and the interdisciplinary teams (IDT) of any issues or concerns warranted in patients. Continued review revealed the nurses performed a daily nursing assessment and notified the Physician, WOCN and RD if needed. RN #5 stated the nurses also attended daily meetings with Pharmacy, Physicians and Case Management to discuss all the systems in place and any areas of concern. Per interview, it was her understanding the facility had a process for monitoring and notification, but she was not sure what that process was. She further stated she believed the nurses were responsible for initiating patients' interventions, such as the additional air mattress device; however, did not recall the device having been initiated for Patient #2. Further interview revealed RN #5 stated it was nursing's responsibility to monitor, and document patients' assessments and notify all needed IDT members, including the Physician.

Interview with RN #3 on 06/01/2022 at 1:41 PM, revealed she had been the Unit Facilitator for the facility's Swing Bed/Acute Care area since March 2022. RN #3 stated it was the RN's responsibility to complete patients' initial body system assessments as well as the initial skin assessment on admission. Per interview, it was her responsibility as well as the RN to monitor and address all patient skin issues and notify the Physician, RD and WOCN if any concerns arose regarding patients. Further interview revealed however, she had not been aware of Patient #2's refusal of care, nor of his/her refusal to turn or eat. RN #3 revealed she had also not been aware of Patient #2 having weight loss or nutritional issues that needed to be further addressed. The RN further revealed the unit needed a process implemented to ensure patients' skin and weights were being monitored daily, interventions were put in place and for ensuring patients' nutritional status were discussed with all the IDT members on a regular basis.

Interview on 06/02/2022 at 1:25 PM with the Interim Director of the Swing Bed/Acute Care Unit (RN #4) revealed her responsibilities included: the "oversight" of the unit; performance improvement; falls; and the monthly dashboard for such items as time critical medication, turnovers, productivity, transfusions and infections. Per interview, her responsibilities did not include monitoring of patients' weight or nutrition. The Director revealed the care nurse assessed any issues with patients' weight, nutrition, or wounds and ensured all patient care areas were monitored, followed and addressed as required. Continued interview revealed the RN's were responsible for alerting the Director, the Physician and any specialty areas of concerns related to patients as necessary. Per the Director, she had never been made aware of Patient #2 refusing his/her care, weights or of any nutritional concerns for the patient. Further interview revealed there was no performance improvement plan in place at that time specifying who was responsible monitoring each care area for patients', such as weights, nutrition or wounds. The Director further stated the nurses should have initiated additional interventions and contacted the Physician and Dietician with any wound, weight and nutritional concerns regarding Patient #2. In addition, the Director revealed the importance of monitoring patients' weights, wounds and nutritional status was to ensure quality of care was provided for the patients.

Interview on 06/09/2022 at 2:35 PM with the Chief Nursing Officer (CNO) and Administrator revealed both expected staff to initiate interventions, contact the Physician, RD, and WOCN with any patient's decline in wounds, weight and nutritional status. The CNO revealed there was no specific staff or department monitoring patients' interventions for wounds, weights or nutritional intake. The CNO and Administrator revealed "someone" needed to have oversight of the care areas and any interventions implemented, with a process for ensuring and promoting standards of care.

Based on interview, record review and review of the facility policy, it was determined the facility failed to develop and implement written policies to ensure one (1) of ten (10) sampled residents was free from abuse, Patient #1.

On 05/21/2022, Patient #1's family member alleged Nurse Aide (NA) #1 and NA #2 had "hurt, mistreated" and caused the patient "pain." However, there was no documented evidence the allegation was reported to the Administrator or State Agencies within two (2) hours. Furthermore, there was no documented evidence of actions taken to ensure other patients were protected from potential abuse after the allegation was made. In addition, there was no documented evidence the allegation was thoroughly investigated as required.

The findings include:

Review of the facility policy titled, "Prevention, Reporting and Investigation of Alleged Patient Abuse by Hospital Associate" approved in June, 2020 revealed the purpose of the policy was to protect patients from abuse and neglect and to define the process by which alleged physical, including verbal and emotional abuse/neglect and mistreatment by associates were investigated and reported. According to the policy, abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Continued review of the policy revealed staff were directed to investigate all allegations of abuse/neglect internally and report the allegation to the State Agencies if the allegation was "credible". The policy review further revealed an internal investigation by the Unit Director and/or Supervisor would be performed immediately upon the report of an allegation of abuse/neglect, and would be reviewed by the facility's Chief Nursing Officer (CNO).

Review of Patient #1's medical record revealed the facility admitted him/her on 05/17/2022, with diagnoses which included Open Reduction with Internal Fixation (ORIF) due to a right humeral fracture (the long bone in the arm that runs from the shoulder to the elbow). Continued review of Patient #1's record revealed the patient's surgical procedure had been completed on 05/12/2022, and the patient was five (5) days post-operative status upon admission at the facility.

Interview with Licensed Practical Nurse (LPN) #1 on 05/27/2022 at 3:30 PM revealed he was caring for Patient #1 on 05/21/2022 when the patient complained of increased pain to his/her right shoulder. LPN #1 stated upon assessment Patient #1's shoulder, arm and hand to his/her right upper extremity was observed as more swollen in appearance. Continued interview revealed Patient #1's provider, Nurse Practitioner (NP) #1 was notified and an order for an x-ray was obtained. LPN #1 further revealed the x-ray obtained indicated Patient #1's "hardware was out" where the surgical repair had previously been completed and had "failed." LPN #1 revealed after the family and Patient #1 were notified of the patient's shoulder "showing" another fracture and that the hardware had failed, the family member confronted NA #1 and NA #2 in the facility hallway. Per interview, the family member alleged that NA #1 had been "rough" with Patient #1 during a transfer and stated "she was the cause of" the patient's failed hardware as she (NA #1) had "mishandled" Patient #1 causing him/her pain. The LPN stated he reported the allegation to the House Supervisor immediately; however, stated he had not been instructed to obtain statements from the persons involved, nor to question Patient #1 regarding the family member's allegation, nor to conduct any investigation activities. Further interview revealed he had been instructed to no longer allow the NA's to enter Patient #1's room after the allegation was made. In addition, LPN #1 further stated the NA's had continued providing care of other patients in the facility however (a timeframe of approximately two {2} hours).

Further review of Patient #1's medical record revealed however, no documented evidence of staff noting LPN #1's abnormal assessment findings on 05/21/2022, regarding the patient's right upper extremity.

Review of Patient #1's x-ray report dated 05/21/2022, of the patient's right shoulder revealed a "displaced" fracture of the proximal humerus and "the mid and distal screws are no longer seated within the humerus."

Interview with NP #1 on 06/03/2022 at 10:00 AM, revealed he was notified on 05/21/2022 that Patient #1 had increased swelling and pain in his/her shoulder, hand and arm of the right upper extremity. He stated he came to the unit to evaluate Patient #1 and upon assessment the patient's right arm, hand and shoulder were "swollen" in appearance. Per NP #1, Patient #1, who was alert and oriented, informed the NP that earlier in the day he/she had "rolled over on it and got it tangled in the bed linen," referencing his/her right arm, and had experienced increased pain since that time. Continued interview revealed Patient #1, nor his/her family member present at the bedside had alleged any abuse or mistreatment by staff at the time, and he informed the patient and family he was going to re-evaluate the patient's shoulder with an x-ray. NP #1 stated after the x-ray was completed and the results indicated the "screws had backed out" he informed Patient #1 and the family member of the abnormal findings and that the patient would need to be transferred for further revaluation. Per the NP, neither the family member or Patient #1 alleged any abuse to him/her from facility staff. Further interview revealed however, LPN #1 had informed the NP of the allegations voiced by Patient #1's family member after the x-ray was obtained and the findings were discussed with the patient and family member. NP #1 revealed he was not aware of abuse reporting guidelines, and as Patient #1 had given an explanation of how the potential injury occurred he had not taken the allegation as credible. The NP further stated he would have expected the facility staff to follow the regulatory guidelines regarding reporting and investigating allegations of abuse in the facility.

Interview on 05/27/2022 at 3:30 PM, with NA #1 revealed she had cared for Patient #1 on 05/21/2022 when the patient's arm was observed to have increased swelling, and an x-ray was performed with abnormal findings identified. She stated after Patient #1 and the family member were informed of the abnormal x-ray findings the patient's family member "confronted" her in the hallway and alleged the NA had "mistreated" and "hurt" Patient #1. Continued interview revealed the family member also alleged NA #1 had caused Patient #1's injury during a transfer, and informed the NA she should not be working in healthcare. NA #1 stated LPN #1 instructed her not to re-enter Patient #1's room and she had not done so. Further interview revealed however, NA #1 reported she continued providing care for other patient in the facility. In addition, NA #1 further stated she had not been asked to complete a witness statement nor do any further actions regarding the alleged incident.

Interview on 05/26/2022 at 2:40 PM, with NA #2 revealed she and NA #1 had been confronted by Patient #1's family member in the facility hallway on 05/21/2022, after the receiving the results of an x-ray which indicated the patient's shoulder was fractured and his/her hardware had failed. She stated the family member "yelled" at both the NA's and alleged that NA #1 had mistreated Patient #1 during a transfer which caused the patient to experience increased pain. Further interview revealed both NA's were instructed by LPN #1 not to go back into Patient #1's room and they had not done so. NA #1 revealed however, both she and NA #1 had continued their duties providing care for other patients. In addition, she stated she had not been questioned any further by facility staff regarding the allegation voiced by Patient #1's family member on 05/21/2022.

Interview on 06/02/2022 at 12:20 PM, with the House Supervisor revealed she had been working on 05/21/2022, when Patient #1's family alleged staff had abused the patient. She stated LPN #1 called and informed her Patient #1's family member alleged the NA's had "jerked" the patient around in his/her room, and caused him/her pain. Per the House Supervisor, LPN #1 reported the family member made the allegation after being informed of the abnormal x-ray which indicated the patient's hardware placed after a shoulder fracture had shifted. Continued interview revealed she immediately reported the allegation received from LPN #1 to the Unit Director and was directed to not allow the NA's to continue to provide care for Patient #1. The House Supervisor revealed however, the NA's had been reassigned to other patients on the unit and had provided care of those patients for the rest of their shift. According to the House Supervisor, as the NP had told her what the patient previously had said, she did not feel there was a problem with letting the NA's continue to work out their shift. She stated she had not been directed to obtain any statements, nor to do any other investigative action after the allegation was voiced by Patient #1's family member. Per interview, she revealed however, she should have probably obtained statements. Further interview revealed she had been trained on abuse; however, was not aware the facility was required to report allegations of abuse to the State Agencies within two (2) hours, and was not aware of any actions taken to protect other patients from potential abuse after the allegation was voiced. Further interview revealed the House Supervisor had not interviewed Patient #1 to assess whether the patient felt staff had abused him/her at the facility.

Interview on 06/02/2022 at 1:25 PM, with the Interim Unit Director revealed she recalled receiving a call from the House Supervisor on 05/21/2022 regarding Patient #1's family member alleging NA #1 had "jerked" the resident. She stated she recalled the allegation had occurred after the family member was informed of an x-ray which had shown Patient #1's shoulder hardware had failed. Continued interview revealed she recalled being told staff had been working on transferring Patient #1 to another facility to be further evaluated after the abnormal x-ray results were received. The Interim Unit Director revealed however, most of the call had been related to report of Patient #1's family member being inappropriate towards staff in the hallway, and she "did not think" the family member's allegation was alleged abuse when informed. She revealed therefore, she had not notified the facility's CNO or Administrator of the incident until the following day, 05/22/2022. Per interview, she had not directed the House Supervisor to conduct an investigation of the alleged incident, or interview Patient #1 regarding the allegation of abuse. The Interim Director stated she was not aware of a two (2) hour reporting requirement for allegations of abuse. Further interview revealed she had also not provided staff with any direction to ensure other patients were protected from further potential abuse after the allegation was received.

Interview on 06/09/2022 at 2:35 PM, with the CNO revealed she was not notified of the allegations voiced by Patient #1's family member on 05/21/2022 until 05/22/2022. She stated she had no concerns regarding the actions taken by facility staff after the allegation was received. Per the CNO, she did not feel the statements made by Patient #1's family member, which had been directed towards the staff regarding their care and treatment of Patient #1, had been alleged abuse. Further interview revealed she was not aware there was a two (2) hour reporting requirement for allegations of abuse to the State Agencies. In addition, she revealed she was not aware an investigation, as well as actions taken to protect other patients from potential abuse during an investigation were also requirements.

Interview on 06/09/2022 at 2:40 PM, with the CEO revealed he had been notified on 05/22/2022, of the allegations made by Patient #1's family member on 05/21/2022. He stated he had not felt the allegation was an allegation of abuse by the family member, and therefore, would not have expected his staff to take any other actions than what was taken on 05/21/2022. Continued interview revealed if he had felt the family member's allegation had been an allegation of abuse he would have reported it to the State Agency, and followed the facility's policy. The CEO revealed however, he was not aware the facility's policy failed to direct staff on the regulatory requirements, and revealed he not aware of the requirement to report allegations of abuse within two (2) hours of the alleged abuse occurrence.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to recognize, evaluate, and address the needs of its residents to include the risk for or actual impaired nutrition in order to maintain acceptable parameters for their nutritional status for one (1) of ten (10) sampled residents, Resident #2.

Resident #2 experienced a significant weight loss of 6.7% in a thirty (30) day period, from 01/07/2022 through 02/07/2022. However, there was no documented evidence the facility's nursing staff supervised and/or monitored Resident #2's weights, and no documented evidence of notification of the resident's weight loss to the Registered Dietician (RD) and the Physician/Medical Provider.

The findings include:

Review of the facility policy titled, "Swing Beds: Nutritional Care," dated 10/22/2019, revealed the facility's nursing services were to ensure residents' necessary care and services through the resident assessment process and the individual plans of care to ensure the nutritional needs of each resident was met. Per policy review, based on each resident's comprehensive assessment, the resident was to receive food in the amount, kind, and consistency that supported their nutritional, therapeutic, psychosocial and special dietary needs. Continued policy review revealed each resident was to be provided the necessary nutrition to maintain acceptable parameters of nutritional status, such as body weight and protein needs, unless documented clinical conditions prohibited the parameters from being sustained. Review revealed residents were to receive a therapeutic diet when there was a nutritional problem identified, and were to be monitored by nursing and dietary staff with response to the nutritional needs of the resident. The policy review revealed staff were to report and document a resident's significant weight loss or gain, and were to use the facility provided formula for determining the percentage of body weight loss and "significant weight loss". According to the policy review, the Physician was to be notified each month as significant gains/losses were noted in the residents. Further review revealed staff were to ensure all residents nutritional and hydration status were monitored on an ongoing basis and documented in their medical records. In addition, the policy review also revealed assistance was to be provided for residents as needed by using adaptive self-help devices, and through offering nutrition and hydration.

Medical record review for Resident #2 revealed the facility admitted him/her on 01/07/2022, with diagnoses to include: Dementia, Declining Functional Status, Depression, Primary Hyperparathyroidism, and Acute Metabolic Encephalopathy. Review of the facility's Registered Nurse (RN) Admission Assessment dated 01/07/2022 for Resident #2 revealed the facility assessed the resident with an Altered Mental Status which required assistance of one (1) staff person's physical assistance with eating meals, including meal tray preparation. The facility initiated a Plan of Care for Resident #2 per the Long Term Care (LTC) Care Plan on 01/17/2022, with a problem noted for the resident as at risk for Altered Nutrition. Continued review of the care plan revealed the goal stated Resident #2 would have no weight loss greater than five (5) % during his/her stay in the facility or within thirty (30) days. Further review revealed the interventions included monitoring Resident #2 for: weight loss; any abnormal labs; and intact skin and report the results to the Physician and Dietician.

Review of Resident #2's laboratory (lab) reports/results revealed the Comprehensive Metabolic Panel (CMP) dated 01/07/2022 results within normal range included:
*Albumin level was 3.7 grams/deciliter (g/dL) normal range was 3.5 to 5.5 g/dL.
*Calcium was 10.0 milligrams per deciliter (mg/dL) normal range was 8.4 to 10.2 mg/dL. *Total Protein 6.3 g/dL normal range was 6.3 to 8.2 g/dL
However, review of the CMP dated 02/07/2022, obtained thirty (30) days later for Resident #2 revealed abnormal results of:
*Albumin level 2.8 g/dL;
*Calcium 8.4 mg/dL;
* and Total Protein 5.3 g/dl.

Review of Resident #2's Nutritional Assessment dated 01/11/2022, four (4) days after his/her admission, completed by the RD revealed the resident had no diet restrictions noted and he/she ate solid food. Per review, the RD had not documented a list of Resident #2's dietary preferences, nor ordered any dietary preferences for the resident. Review revealed Resident #2 was currently receiving a regular diet and his/her admission weight was documented as "stable" at 167 pounds (lbs). Continued review revealed the RD had noted Resident #2's nutritional lab value on 01/11/2022, and documented his/her skin as intact. Per review, the RD Nutrition Therapy Plan revealed documentation of Resident #2 having "poor" by mouth (PO) intake which was noted as 20% times five (5) meals for the resident. Review revealed the RD noted the "hostess" was to work with Resident #2 for "menu preferences" and encourage greater PO intake. Per review, the RD recommended to add Boost Plus supplements to Resident #2's meals and to consider enteral nutrition (tube feedings) if PO remained less than 25% as per the resident's and family wishes. Further review revealed the RD placed Resident #2 on a low nutrition risk and the Medical Nutrition Therapy Plan on the RD's assessment form noted the RD was to monitor the resident's nutritional status. However, medical record review revealed the RD did not reassess or reevaluate or follow up on Resident #2's nutritional status again until 02/02/2022 (approximately nineteen {19} days later), with no documented evidence of communication with dietary and nursing staff, the resident and/or his/her family; nor of the Physician having been notified, or of additional interventions implemented.

Review of the Nursing Progress Notes for Resident #2 from 01/07/2022 to 02/16/2022, revealed no documented evidence of Physician notification of the RD's recommendations on 01/11/2022. Continued review of the Nursing Progress Notes revealed no documented evidence the RD reassessed Resident #2 for any weight changes, poor nutritional outcomes or the effectiveness of the recommended interventions again until the documentation dated 02/02/2022 (a period of over three {3} weeks). Additionally, review of Resident #2's medical record revealed on 01/15/2022, a facility acquired PU was noted to Resident #2's coccyx; however, there was no documentation noting RD notification and assessment or of nutritional and/or supplemental interventions implemented to promote wound healing for the resident.

Review of Resident #2's Intake record for meals for the time period of 01/07/2022 through 02/07/2022, revealed the resident's meal intakes were 50% (fifty percent) or less for most meals during that timeframe. Review of the Nursing Assessment record for Resident #2 revealed multiple days in January and February 2022 that nursing staff documented the resident's PO intake as less than 50% for six (6) consecutive meals and noted he/she needed assistance with meals. However, continued review of the Nursing Assessment record for Resident #2 revealed under the Intake and Output documentation section the "no oral supplement provided" was marked as "yes"; and the feeding options area was documented as, "Left Tray" and with no documented evidence assistance was provided for the resident.

Review of Resident #2's weights obtained by the facility for the timeframe of 01/07/2022 through 02/07/2022, revealed the following: 167.3 pounds (lbs) on 01/07/2022; 158.1 lbs on 01/14/2022; and 149.2 lbs on 01/30/2022, a total loss of 18.1 lbs during that time period. Resident #2's 18.1 lb weight loss over a thirty (30) day period was indicative of a significant weight loss; however, further review of the resident's medical record revealed no documented evidence the RD or the Physician had been notified or were aware of the significant weight loss.

Interview with Dietary Host (DH) #1 on 06/07/2022 at 3:25 PM, revealed his job duties consisted of interacting and communicating with the "patients", delivering residents' menus and assisting them to plan their meals. He stated if a "patient" was unable to communicate, he asked the resident's family to assist with meal preferences, if they were present at the resident's bedside. Per DH #1, the residents likes/dislikes were discussed and that information was shared with nursing staff. Continued interview revealed DH #1's duties also included delivering and picking up residents' meal trays and recording the percentage of their food and fluid intake. He revealed the recording of residents' meal intake included noting any supplements which was recorded under the "supplement tab." DH #1 revealed he had not been trained to report any decrease of intake for a resident, or on monitoring residents' meal percentage to any "certain degree." The DH stated he had not been trained on ensuring if a resident's intake was low for consecutive meals to inform "someone" about it. According to DH #1, if he noticed a "patient" was not eating "good" for long periods of time, he would tell his Dietary Manager. Interview revealed however, DH #1 denied communicating with the RD, for any reason. DH #1 stated dietary staff delivered residents' snacks to the units, but did not monitor the percentage consumed by the "patients," as dietary staff were not responsible for documenting that information. Further interview revealed he did not attend any meetings or discuss patients' intake concerns with nursing staff, and was not aware of anything to do with their wounds. DH #1 further stated he was not aware of any "patients" with weight loss or gains, he had not been trained by the facility, and did not have the ability to do a RD consult for "patient" concerns.

Interview on 06/07/2022 at 3:35 PM, with Dietary Manager (DM) #1 revealed she had been in her position for two (2) years. Per interview, the DM's responsibilities included delivering and picking up residents' meal trays, and recording the percentage eaten by the residents in their medical records. Continued interview revealed the DM denied receiving any type of training to monitor the percentage of residents' intake at meals in order to identify any trends or concerns, and also had not been trained on reviewing "patients" weights. DM #1 stated she only had access to the Physician's Orders and that was only to print off and review for any "patient" diet orders or if a supplement had been ordered to be placed on a resident's tray. DM #1 revealed she did not monitor "patients" weights, nor their intake/output or had not been trained on who was experiencing weight loss in the facility. Further interview revealed she was not sure what "significant weight loss" meant for a resident. DM #1 further stated the dietary department did not do RD referrals for any reason and had never been told to do that. Additionally, DM #1 revealed she felt it would be beneficial to know about "patients" conditions, and it would be good to have a process for the dietary department to have "someone" monitoring those specific things.

Interview on 05/26/2022 at 2:00 PM, with Personal Care Technician (PCT) #1, revealed the PCT's were responsible for obtaining residents' weights, and the nurses were responsible for monitoring their weights for weight gains and losses. Continued interview with PCT #1 revealed Resident #2 had been "pleasantly confused" throughout his/her stay at the facility and required staff to set up his/her meal trays and encourage him/her with eating. PCT #1 stated Resident #2 refused meals most of the time during the first part of his/her admission; however, towards the end of his/her stay the resident was eating very well on his/her own. Additionally, PCT #1 did not recall any discussion with nursing staff regarding concerns for Resident #2 or monitoring of his/her weight related to the resident's nutritional status or of any dietary adjustment with the resident's meal intake.

Interview on 06/02/2022 at 9:06 PM, with PCT #4 revealed PCT's obtained residents' weights as instructed per the nurses and as received in report. He stated the PCT's were responsible for recording residents' weights and heights and the nurses were responsible for looking back and comparing and monitoring the residents' recorded weights. Continued interview revealed all newly admitted residents weights were obtained on admission and daily for five (5) days, and then obtained weekly. PCT #4 further stated he recalled Resident #2 having difficulty eating on dayshift, but had not seen any issues with the resident's weight or his/her eating on night shift.

Interview on 06/01/2022 at 1:20 PM, with Licensed Practical Nurse (LPN) #2, revealed the PCT's were responsible for obtaining residents' weights; however, revealed the facility had no "specific process" for nurses to monitor the weights. LPN #2 stated nurses did document and were aware of residents' weights through the assessment charting. Continued interview revealed if a resident experienced a significant weight loss or gain which was identified during the charting assessment or if a PCT alerted the nurses with a concern about a resident, then the nurse was to monitor the resident, and notify the RD and the Physician. She stated it was her understanding if a resident had a plus or minus of five percent (5%) weight change then the percentage of weight would be automatically generated on a report for the RD to review. Further interview revealed LPN #2 had not been aware of Resident #2's weight loss issues or concerns other than the resident had required his/her food set up on the meal tray, and required assistance and encouragement with his/her meals at times.

Interview on 06/06/2022 at 5:55 PM, with Registered Nurse (RN) #5 revealed the nurses were responsible for looking at residents' daily and weekly weights, wounds, percentage of their meal and fluid intakes and their output per shift. Per interview, nurses were also responsible for knowing residents' past history and their current medical diagnoses which all factored in when the nurse was monitoring a resident's weight. She stated it was nursing's responsibility to notify the Physician, RD and interdisciplinary teams of any issues or concerns warranted. RN #5 stated the nurses did a daily weight assessment and notified the Physician and RD if needed, and attended daily meetings with pharmacy, Physicians and case management to discuss all systems and any areas of concern. Continued interview revealed it was her understanding the facility had a process for monitoring and notification of the Physician and RD; however, she was not sure. RN #5 revealed she believed if a resident experienced a plus or minus 5% weight change, the percentage of weight automatically generated or alerted on a report/board for the RD to review. Further interview revealed if a resident had weight loss or had wounds the RD would order a nutritional supplement or an intervention to meet the resident's caloric needs. RN #2 further stated she had not identified changes in Resident #2's weights, but revealed after reviewing of Resident #2's weights, that she was concerned about his/her weight loss as that weight loss could have affected his/her wound healing. In addition, RN #5 revealed the RD and the Physician should have been notified of Resident #2's weight loss.

Interview with RN #3, the Unit Facilitator on 06/01/2022 at 1:41 PM, revealed she had been in her position as Unit Facilitator since March 2022. RN #3 stated it was the RN's responsibility for completing newly admitted residents' initial body system assessments as well as their initial skin assessment. Continued interview revealed it was her responsibility as well as the RNs to monitor and address all residents' weights and notify the Physician and RD of any concern regarding nutritional issues or weight loss/gain in the residents. She stated however, she was not aware Resident #2 having experienced weight loss or nutritional issues which had needed to be addressed. Further interview revealed her unit needed a process put into place to ensure residents' weights were being monitored daily and their nutritional status was being discussed with all the interdisciplinary team members on a regular basis.

Interview with the Interim Director of the Swing Bed/Acute Care unit on 06/02/2022 at 1:25 PM, revealed her responsibilities included oversight of the unit. The Interim Director revealed her responsibilities involved performance improvement, monitoring residents' falls, the monthly dashboard, such as time critical medications, turnovers, productivity, transfusions and infections. Continued interview revealed however, her responsibilities did not include weight or nutrition monitoring for residents. The Director stated the care nurses assessed any issues, such as weight, nutrition, wounds and ensured all the residents' care areas were being monitored, followed and addressed. She revealed the RN was responsible for notifying the Director, the Physician and any specialty areas as warranted. Further interview revealed she had not been made aware of any weight or nutritional concerns for Resident #2; however, stated the nurses should have contacted the Physician and Dietician with any weight and nutritional concerns. Additional interview revealed there was no performance improvement plan in place at that time specifying who was responsible for monitoring each care area for the residents, such as weights, nutrition or wounds. The Director further revealed it was important to monitor residents' weights, wounds and nutritional status to ensure quality of care.

Interview on 06/03/2022 at 11:13 AM, with the RD revealed she evaluated all admissions within forty-eight (48) hours and if the resident had skin breakdown or weight loss the system would trigger if a consult was required. RD revealed Resident #2 admission's intake had been a level 1, which was a low risk on the Braden scale (for skin breakdown). Continued interview revealed the nurse was responsible for contacting the Dietician of any nutritional issues or weight loss that occurred in residents. The RD stated the facility's computer system would also trigger the "Dietary Dashboard sheet" to alert the RD of residents' wounds, unintentional weight loss and the sheet was printed off on a daily basis. Per interview, even though the "Dietary Dashboard sheet" was printed off daily, the nurses should still send that notification to the RD as well. The RD revealed however, the Dietary Department never received notification from nursing that Resident #2 had only been eating 25-50% (percent) or less of his/her meals. Per the RD, she did not have a designated date to meet with the interdisciplinary teams to discuss any resident issues or decline, but did communicate with all areas as needed. Further interview revealed the RD had not been aware of concerns with Resident #2's nutritional or weight status until the State Surveyor revealed the weights and decline in nutritional intake, as well as the facility acquired wound. In addition, she stated there definitely needed to be a better notification process and monitoring system in place for each department, in order to do the "right thing" for all residents.

Interview on 06/09/2022 at 2:35 PM, with the Chief Nursing Officer (CNO) and Administrator revealed both expected staff to contact the RD and Physician of any resident's decline in nutritional and weight status. The CNO revealed there was no specific department or staff assigned for the monitoring of residents' weights and nutritional intake. The CNO and Administrator further revealed "someone" needed to be providing oversight of resident care areas and implement an necessary interventions to ensure and promote the standards of care.