Health inspection·November 8, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility neglected to monitor a resident's change in condition, follow the orders to monitor a resident's vital signs and blood pressure as ordered and failed to notify the advanced practice nurse of signs and symptoms of a stroke. This failure resulted in a delay of treatment for R1 and causing a hemorrhagic stroke and right-sided weakness. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for facility response to change in condition and treatment in a sample of 3. The findings include: R1 is a [AGE] year-old male admitted on [DATE] having a mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 11/07/23 at 10:15 AM, V8 (Hospital Registered Nurse) stated, On 10/31/23, R1 said to multiple staff at multiple times to send him to ER (Emergency Room) as he was experiencing right side numbness and tingling. But they don't let him for whatever reason. R1 said he began to tell people to send him to the hospital on [DATE] at around 9-10 AM. He was sent to our ER on [DATE] with a right-side weakness and facial droop. He had a Hemorrhagic stroke as per CT (Computerized Tomography) scan. On 11/2/23 at 12:40 PM, V9 (Hospital [NAME] President of Nursing) stated, R1 was transferred to another hospital as we don't have any neurosurgeon available with our hospital. On 11/2/23 at 5:45 PM, R1 was observed in the neurology unit of the second hospital. R1 was observed on his bed, with his right sided weakness. R1 was unable to lift his right arm or right leg. On 11/2/23 at 5:45 PM, R1 stated, I know my body, and I knew something was going wrong on Tuesday, 10/31/23. I was so scared as I had numbness and tingling in my right arm. I told my nurse to send me to hospital right away. My nurse was V5 and said 'No' to my request. On 11/2/23 at 5:50 PM, V10 (Hospital Registered Nurse) stated, I just received R1 from neuro ICU (Intensive Care Unit) to regular neuro floor. R1 had a thrombectomy done due to his stroke, and his right side is weak. On 11/2/23 at 1:45 PM, V5 (R1's nurse on 10/31/23 Day Shift) stated, On 10/31/23, R1 was complaining of right arm tingling/numbness. I took his vitals, and his blood pressure (BP) was elevated at 177/102. I notified the nurse practitioner about his elevated blood pressure, who ordered Metoprolol and Hydralazine. Page 1 of 2 146112 146112 11/08/2023 Arc at Bradley 650 North Kinzie Ave Bradley, IL 60915

F 0684 Level of Harm - Actual harm Residents Affected - Few On 11/2/23 at 11:00 AM, V6 (Nurse Practitioner/NP) stated, One of the Physical therapists called me saying that R1 was not feeling well. I assessed him, and he said he was not feeling well after breakfast. He was feeling dizzy. He was afebrile not complaining of chest pain. His BP was elevated at 172/109. When I checked his medication profile, there were no BP medications on his medication list. So, I ordered metoprolol 50 mg daily and Hydrochlorothiazide 25 mg. I was not notified of his right-side tingling. I would have ordered a CT if I knew he had right-side tingling along with elevated blood pressure. They should have notified the provider if R1 continued to have numbness and tingling after blood pressure medication was given. On 11/2/23 at 1:45 PM, V5 added, Maybe I didn't mention R1's right arm tingling/numbness to NP because I was worried too much about his blood pressure. I endorsed to the night nurse to monitor him as he was given two blood pressure medications (new to R1) due to his elevated BP. Record review on progress note and vitals record indicates that R1's vital signs and BP were not monitored or documented during the night shift of 10-31-2023. On 11/2/23 at 1:45 PM, V12 (R1's agency CNA on 10/31/23 night shift) stated. I am not supposed to do vitals unless the nurse tells me to take vitals. The nurse on duty that night was an agency nurse, V13. V12 stated V13 never requested to have R1's vital signs and blood pressure monitored. V13 was not available for interview during the investigation. V12 added, nurses are the ones who usually take vitals and V12 was unsure if V13 monitored R1's blood pressure and vital signs. On 11/2/23 at 10:25 AM, V11 (Registered Nurse for R1 on 11/1/23 AM shift) stated, I worked yesterday, and I was the one who transferred R1 to the hospital at around 6:20 AM. My CNA (Certified Nursing Assistant) notified me that R1 was found on the floor while I was getting the shift report at around 6:15 AM. He was bleeding from his right eyebrow. His BP was high at 157/95. He was not on any BP medications and was very independent. R1 told me that he also reported to the night nurse about his right arm numbness/tingling. On 11/2/23 at 10:25 AM, V11 added, The night agency nurse (V13 was unavailable for the investigation) endorsed me to monitor R1 due to his increased confusion. She (V13) never mentioned to me about his right-side numbness. R1 had slurred speech and elevated BP, and his arm strength was not symmetrical when I assessed him after the fall. He was telling me something was happening to him and sending him out to the hospital. R1 is a resident who never calls for unnecessary things. If he complains about something, there is something serious, and the staff should listen to him closely. When I called the hospital for follow-up, the nurse told me that R1 was admitted there for hemorrhagic stroke. Record review on Emergency Department Physician Report dated 11/01/23 (Page 5/15) documents that R1 arrived in ER with right-sided facial droop, right upper and lower extremity weakness, right-sided sensory deficit, mild dysarthria, and aphasia concerning acute stroke. The ER physician report documented that the patient is outside of the window for TNK administration (clot buster). CT of the head demonstrated acute intraparenchymal hemorrhage in the left globus pallidus. On 11/7/23 at 12:00 PM, V2 (Director of Nursing / DON) stated, I was here on 10/31, and I knew about R1's elevated BP. I wasn't notified of his numbness and tingling even after his blood pressure came down. The nurses should have notified the Physician/NP If he still felt numbness. 146112 Page 2 of 2