**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation, policies and procedures, the facility failed to ensure that one resident (#5) was free from neglect by failing to ensure oxygen was administered when needed and the provider was notified of decreased oxygen saturation. The deficient practice resulted in cardiopulmonary arrest and hospitalization for resident #5. Findings include: Resident #5 was admitted on [DATE] with diagnoses of multiple sclerosis (MS), epilepsy, and hypertension. The care plan dated [DATE] revealed the resident was admitted due to decreased activities of daily living (ADLs) ability related to MS exacerbation/flare with seizure disorder. Another care plan initiated on [DATE] indicated that the resident had potential for pain/discomfort related to MS flare, neuropath, and decreased mobility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The assessment also included the resident was not coded for shortness of breath, was not on oxygen therapy and did not have a condition or chronic disease that may result in a life expectancy of less than 6-months. The active physician order summary revealed no orders for supplemental oxygen use. The weights and vitals summary report from [DATE] through 29, 2023 revealed resident had oxygen saturation (O2 sat) rate reading ranging 90-98%. The skilled note dated [DATE] revealed the resident was alert and oriented to person, place and time, had no shortness of breath and had O2 sat rate of 95% on [DATE] at 6:46 a.m. The weight and vitals summary report revealed the resident's O2 sat rate were as follows on [DATE]: -At 3:07 p.m. - 87% in room air; and, -At 10:57 p.m. - 81% room air. A late entry physician progress note dated [DATE] included that the resident's O2 sat was 71% on room air based on vitals taken on [DATE] at 5:15 a.m. Per the documentation, the resident was not in great pain, was working on a bike machine, did not have cyanosis and bilateral lung sounds were clear to auscultation. A skilled note dated [DATE] at 3:17 a.m. included the resident's O2 sat was 81% on room air based on vital taken on [DATE] at 10:57 p.m. The note also indicated that the resident was not experiencing shortness of breath and was not on oxygen therapy. The documentation did not indicate any actions taken to address the resident's low O2 sat; and that, the physician was notified. Despite documentation of low oxygen saturation rates, the clinical record revealed no evidence that interventions were put in place to address the resident's oxygen saturation; and that, the physician was notified from [DATE] at 3:07 p.m. through [DATE] before 5:04 a.m. A general note dated [DATE] at 5:04 a.m. revealed resident #5 was alert and oriented was having respiratory difficulty and was cool and clammy. The documentation the note indicated that 911 was called and that the medical doctor was notified. The weight and vitals summary report for [DATE] 5:15 a.m. revealed the resident had an oxygen saturation rate of 71% via nasal cannula A progress note dated [DATE] at 5:15 a.m. included the resident had moderate emesis of brown liquid substance, was breathing and was unresponsive. Per the documentation, CPR (cardiopulmonary resuscitation) was initiated for 15 minutes by paramedics, and that the resident left the facility at 5:35 a.m. A progress note dated [DATE] at 5:25 a.m. revealed that the ambulance arrived at 5:15 a.m.; and that, CPR was initiated. The transfer/discharge summary note dated [DATE] at 7:37 a.m. included that resident #5 left the facility at 5:35 a.m. with mechanical CPR device delivering chest compressions; and that, the resident was taken to the hospital. Per the documentation, staff spoke with the ER (emergency room) nurse; and that, the resident expired in the hospital. A review of a written statement by staff #117 dated [DATE] revealed that on [DATE], the CNA took the resident's vital signs on or about approximately between the time of 12 midnoc (midnight) and 1:00 a.m. indicated that a CNA informed her that resident #5's O2 sat was 91%. Per the statement, staff #117 noticed the documentation in the electronic record upon entering the patient's room on or about approximately 5:15 a.m. was 81% the O2 sat. At approximately on or about before 5:15 a.m., two CNAs and the nurse (staff #117) entered resident's room. Per the documentation, the resident's family reported that the resident had been like this during the night, the resident needed oxygen and the physician saw the resident today. The statement also included that the resident was awake, responsive and breathing, had an O2 saturation of 71%; and that, staff #117 placed the resident on oxygen at 2-3 LPM (liters per minute) continuously, exited the room, called 911 and notified the physician. The statement also included that the paramedics arrived at or approximately before or after 5:15 a.m. and the resident was placed on cardiac monitor. It also included that the resident had large emesis of brown liquidy substance; and, the paramedics immediately started mechanical chest compressions and that, the resident was still breathing. The statement also included that the resident left the facility at or about approximately before or after 5:30 a.m. and was transported to the hospital; and that, later on that morning of [DATE], staff #117 called the hospital and was informed that the resident expired. The facility 5-day report submitted on [DATE] revealed that a certified nurse assistant (CNA/staff #47) reported that when she took the resident's vital signs on [DATE] at 10:30 a.m. the resident's oxygen saturation was 81%; and that, she immediately reported the reading to the nurse (staff #117). The report also included that the CNA reported that oxygen was not initiated until the resident was found in distress at 4:45 a.m. on [DATE]. The documentation also included that interviews conducted with staff who worked with staff #117 revealed that staff #117 had problems with time management and follow through; and that, staff #117 seemed to be behind in her work and in a rush and there were instances when the staff had to finish up for staff #117 and follow through on work. The investigative report also included that on [DATE] the director of nursing (DON) spoke with staff #117 who said that the CNA (staff #47) informed her at 10:30 p.m. of [DATE] that the resident had low oxygen saturation but she did not enter the resident's room until 4:45 a.m. the next morning ([DATE]) when the resident was found to be slow to respond and had an oxygen saturation of 45%. Continued review of the report included that there were no progress notes written by staff #117 regarding the resident's health status or any action taken to address the resident's oxygen saturation of 81% at 10:30 p.m. on [DATE] and there was nothing in the medical record that indicated the resident was started on oxygen. Further, the investigative report included that the allegation neglect was substantiated. A phone interview was conducted on [DATE] at 12:44 pm. with the CNA (staff #47) who reported the incident. The CNA stated that she provides direct care for residents including responding to call lights and checking on issues or concerns the resident have; and that, if she notices a change of condition or something outside of the resident's baseline, she will immediately inform the nurse. The CNA stated that it was neglect if someone fails to act or provide a service that the resident needs; and that, instances of abuse/neglect are reported to the administrator or the DON. Regarding resident #5, the CNA stated that she was familiar with resident #5 and she had taken care of the resident for a few weeks. The CNA said that she was working double that day the incident with resident #5 occurred. She stated that the resident's oxygen saturation (O2 sat) normally range between 90-91%; and that, at around 2:30 p.m. on [DATE], the resident's O2 sat was low at 87%. The CNA said that she informed the nurse about the low O2 sat and the resident's family concern about the resident having a fever despite the resident having no high temperature. temperature. The CNA stated that at around 10:30 p.m. on [DATE], she took the resident's vitals again and the resident's O2 sat would not go above 81%. She stated that she informed the LPN (staff #117) who told her that they will give the resident oxygen; and that, she thought the LPN (staff #117) went to check on the resident. However, the CNA said that at around 4:45 a.m. the next morning ([DATE]), she got done with her rounds, went to check on resident #5 and when she turned on the light, the resident had a dead stare and was blue. The CNA said that she placed a pulse oximeter on the resident and the O2 sat reading was 45% and the resident did not have oxygen on. The CNA said she reported the reading to the LPN who then called 911 and the doctor; and that, when the paramedics arrived, the resident still had a pulse but was not very alert or oriented. She said that about 5 minutes later, the paramedics started CPR and then transported her to the next-door hospital. Further, the CNA stated that later on that day she found out that the resident had passed away. The CNA stated that she was under the impression that the LPN (staff #117) would have given oxygen to the resident after she informed the LPN that the resident's O2 sat was low; and that, he did not know that the nurse did not check on the resident. Furthermore, the CNA stated that she would have expected the LPN (staff #117) contacted the doctor regarding the resident's low O2 sat but she was not sure if that happened that night. During a phone interview with the medical doctor (MD/staff #116) conducted on [DATE] at 1:36 p.m. the MD stated that he normally sees the residents every other day, which amounts to three times a week; and, he was supposed to be notified by the nurse if a resident has a change of condition or a change in their baseline. The MD said that he would not necessarily say it was neglect if staff fail to act or provide a service which includes notifying him so he can formulate a course of action/treatment. However, he does expect to be notified in those situations. Regarding resident #5, the MD stated that resident #5 was a really nice resident who was in the pre-end stage of MS (multiple sclerosis) and came to the facility to become stronger and was on rehab but was not making much progress. The MD said that he first found out about the resident's low O2 stat in the early morning of [DATE] and he ordered for the nurse to call 911 and to send the resident to the hospital. Further, the MD stated that the resident became hypoxic and this led to the resident's hospital transfer. However, the MD said that he was not sure why she became hypoxic and all he could remembered was that he got a call from a nurse really early in the morning. The MD stated that CPR was initiated but the resident was not resuscitated. Further, the MD said that he was the one who signed off on the resident's cause of death which was acute hypoxic respiratory failure. An interview was conducted on [DATE] at 2:16 p.m. with the DON (staff #31) who stated that the expectation was for staff to notify the doctor and the family when a change of condition occurs or if there was something out of the resident's baseline. The DON stated that it was neglect if the staff failed to provide a service that a resident medically need. Regarding resident #5, the DON stated that she was not familiar with resident #5 but she knows the resident was admitted to the facility with MS flare up. The DON said that it was a concern that resident #5's O2 sat was low; and that, the nurse (staff #117) should have called the doctor, administered oxygen to the resident as an emergency, re-checked the O2 sat and started treatment. The DON also said that the resident was transferred to the hospital because the resident coded and vomited while the paramedics were in the facility. Further, the DON stated that the facility investigation concluded that oxygen was not initiated or administered to resident #5. Regarding the alleged LPN (staff #117), the DON stated that the only complaint she had heard was that the LPN (staff #117) worked slow due to her being older. The DON said that the LPN (staff #117) did not have a history or pattern of behavior against the LPN regarding resident care. Further, the DON stated that the LPN (staff #117) after the incident, the LPN never came back for work and had since resigned. The facility policy on Change of Resident Condition with an effective date of [DATE] revealed that in order to minimize unplanned hospital transfers and ensure that residents do not experience preventable declines in condition, the facility will use a consistent approach in identifying, managing and communicating changes in resident condition. It also included that the nurse will assess the resident's symptoms and physical function and document detailed descriptions of observations and findings; and that, the physician should be notified of all changes in a resident's condition. Furthermore, the policy included that the nurse will document in the nurse's notes, the date, time and parties notified. Documentation will include enough information to describe the situation and indicate how it is being handled. Condition changes that may require physician intervention included tachypnea and dyspnea with a pulse oximetry of lower than 90%. The facility's undated policy on Documentation included that it was their policy that nursing personnel complete documentation requirements each shift and as soon as possible after a resident event. It also included that LPN documentation requirements included complete documentation for any change in resident condition, interventions and resident response; and, to continue documentation as often as the condition warrants and at minimum of every shift times 72 hours or until condition stabilizes or resolves. The facility's undated guide on Oxygen Administration included a purpose to deliver oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; and that, oxygen administration is the basic responsibility of a licensed nurse. Assessment guidelines may include but are not limited to respiratory distress and pulse oximetry and to document the condition of the resident before procedure and effectiveness of oxygen therapy, vital signs before oxygen was started and periodically after initiation of therapy. Review of a facility policy titled Abuse Prevention Policy & Procedure revised [DATE] revealed that it is the responsibility of all employees to immediately report any suspected or alleged violation of abuse, neglect, injuries of unknown origin, and misappropriation of resident property. Additionally, the policy noted that the facility takes appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin, exploitation, and misappropriation of resident property. The policy also defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.