**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three (#2, #8 and #9) of five residents reviewed for quality of care out of nine sample residents, received treatment and care in accordance with professional standards of practice. Specifically: The facility failed to ensure that registered nurse (RN) #2 promptly identified, intervened, monitored, and consulted with Resident #2's physician when the resident experienced a change of condition. The facility admitted Resident #2 on [DATE] for rehabilitation after abdominal surgery. On [DATE] at 4:13 a.m., the night nurse, registered nurse (RN) #2, documented the resident had labored breathing and a decreased oxygen saturation level. RN #2 documented she increased the resident's oxygen, but his breathing remained labored so she raised the head of his bed. There was no further assessment of Resident #2 at that time; RN #2 did not document vital signs (pulse, blood pressure, or respiratory rate) or assess his response to her interventions. Specifically, there was no documentation that the RN conducted a comprehensive assessment of the resident's respiratory status, or assessed the resident for pain, change in mental status, or skin color. Finally, RN #2 did not notify and consult with the resident's physician about the resident's labored respirations and increased oxygen needs. Although RN #2 documented, will continue to monitor (Resident #2), RN #2 failed to do so, either to evaluate Resident #2's response to her interventions or to assess the resident for continuing and/or additional signs of distress. Record review revealed RN #1, the oncoming day nurse, documented on [DATE] at 6:30 a.m., that the night nurse (RN #2) was giving report to her and licensed practical nurse (LPN) #1 when a certified nurse aide (CNA) came and told them Resident #2 did not look good, looked like he was transitioning (first stage, before actively dying). At that time, RN #1 entered the resident's room and found him unresponsive, gray in color, barely breathing, but with a pulse. Staff contacted emergency medical services (EMS) and, consistent with the resident's wishes (full code/full treatment), cardiopulmonary resuscitation (CPR) was initiated. EMS transported the resident to the hospital where he was transferred to the intensive care unit. Hospital staff instituted life support measures until they were terminated at the family's request and the resident expired at 11:44 a.m. Hospital records documented the resident had a cardiac arrest and acute respiratory failure, probably due to myocardial infarction (heart attack), possibly due to septic shock. RN #1 and LPN #1, in separate interviews, said RN #2 told them the resident had difficulty (labored) breathing for hours throughout the night. Additionally, the interviews revealed that RN #2 said she never went back to check Resident #2 because she was busy with medications to pass and paperwork. An interview with RN #2 revealed she was not sure what to do that night. Additionally, she said she was busy, and had medications to pass and paperwork to do. RN #2 confirmed she never went back to check Resident #2. RN #2 also confirmed she had not monitored the resident or evaluated his response to increased oxygen or to raising the head of the bed. RN #2's failure to timely assess, monitor, intervene, and consult with Resident #2's physician following the resident's change of condition contributed to an immediate jeopardy situation and to Resident #2 sustaining serious harm. Record review and interviews revealed the facility responded to the events on [DATE], in-servicing staff and developing a plan of correction that included training 100 % of staff; however, the facility's actions were not effective in addressing RN #2's response to residents' changes in condition. Record review and interview revealed that, contrary to facility expectations and training after [DATE], RN #2 failed to assess, monitor, document, and consult with the physician following Resident #8's change of condition in the early morning on [DATE], as well as Resident #9's change of condition in the early morning on [DATE]. Cross-reference F726: the facility failed to ensure licensed nurses were competent to respond to residents' changes of condition. Findings include: I. Immediate jeopardy Resident #2 experienced a change of condition in the early morning hours on [DATE] with labored breathing and decreased oxygen saturation levels. RN #2 documented she increased the resident's oxygen, but the resident's breathing remained labored so she raised the head of his bed. There was no further assessment of Resident #2 at that time; RN #2 did not document vital signs or document the resident's response to her interventions. Specifically, she did not document an assessment of the resident's respiratory status, or assess the resident for pain, a change in mental status, or skin color. Finally, RN #2 did not notify and consult with the resident's physician about the resident's labored respirations and increased oxygen needs. Although RN #2 documented, will continue to monitor (Resident #2), RN #2 failed to do so, either to evaluate Resident #2's response to her interventions or to assess the resident for continuing and/or additional signs of distress. Day shift staff (RN #1 and licensed practical nurse (LPN) #1) entered the resident's room at around 6:30 a.m. after receiving a report by a CNA that Resident #1 did not look good; she found the resident unresponsive, gray in color, barely breathing but with a pulse. She contacted emergency medical services (EMS) and, consistent with the resident's wishes (full code/full treatment), cardiopulmonary resuscitation (CPR) was initiated. EMS transported the resident to the hospital where he expired at 11:44 a.m. after the family requested that life support measures be terminated. Hospital records documented the resident had a cardiac arrest and acute respiratory failure, probably due to myocardial infarction (heart attack), possibly due to septic shock. The facility's failure to ensure RN #2 provided treatment and services consistent with professional standards of practice created a situation of immediate jeopardy for serious harm. II. Facility Response to immediate jeopardy A. The nursing home administrator (NHA) was notified of the immediate jeopardy situation on [DATE] at 5:11 p.m. and again on [DATE] at 9:45 a.m. On [DATE], the NHA provided the facility's plan to address the events on [DATE]. The plan was reviewed on [DATE] at 9:04 a.m. and again on [DATE] at 9:45 a.m. The plan read: -100% of education of nurses; -Morning meeting review with IDT (interdisciplinary team) of any change of condition for compliance of documentation; -Morning meeting review with IDT of any change of condition for compliance of MD (physician) notification; -Monthly review of all change of condition; -Review all change of conditions for trends and opportunity for improvement in QAPI (quality assurance program initiative); -If fall or skin do risk management; -Re-inservice nursing staff; -Medical director chart review of (Resident #2); and, -Ad hoc (as needed) QAPI for this PIP (process improvement plan). The facility's plan, dated [DATE], was accepted on [DATE] at 9:33 a.m. and reaffirmed on [DATE] at 9:45 a.m. and the immediate jeopardy was removed. However, the deficient practice remained at a G level, actual harm that was isolated. III. Expectations - Resident Change of Condition A. Facility policy and procedure The Significant Change Condition policy, revised 1/2022, was received from the director of nursing (DON) on [DATE] at 5:45 p.m. It read, in pertinent part, If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): Change or a trending change in vital signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturation. The Nurse will perform and document an assessment of the resident and identify the need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR (Situation, Background, Assessment, Recommendation) or similar process to obtain new orders or interventions. B. Staff interviews on facility expectations 1. RN #1 was interviewed on [DATE] at 12:42 p.m. RN #1 said when a resident has a change of condition, the licensed nurse should assess the resident, fill out a change of condition form, check the resident's code status wishes, notify the family, notify nursing management and notify the physician. 2. The assistant director of nursing (ADON), who was responsible for reviewing nursing charting for physician notification and documentation with changes of condition, was interviewed on [DATE] at 1:00 p.m. The ADON said when a resident experienced a change of condition, the licensed nurse should conduct an assessment, complete necessary documentation, and notify the family and physician. She said if a resident was experiencing shortness of breath, the licensed nurse should complete an assessment, notify the physician and follow the physician's orders. 3. The director of nursing (DON) was interviewed on [DATE] at 1:21 p.m. and on [DATE] at 4:35 p.m. The DON said if a resident experienced a change of condition, she would expect the licensed nurse to do an assessment, document the assessment, notify the physician and family, and determine any interventions. The DON said current vitals should be taken when a resident was experiencing a change of condition. IV. Events on [DATE] involving RN #2 and Resident #2 RN #2 failed to provide Resident #2 with treatment and services consistent with professional standards of practice to avoid physical harm following his change of condition. A. RN #2 1. Interview a. The ADON was interviewed on [DATE] at 1:00 p.m. -The ADON said RN #2 had been at the facility for a few months (hire date [DATE]) and had resigned last Thursday or Friday. The ADON said she understood RN #2 was an experienced nurse and she knew the RN worked nights. -The ADON said the licensed nurse (LN) new hire orientation consisted of a day with human resources reviewing videos and paperwork. She said then the LN was scheduled by the DON for orientation with another LN on the floor. She said the LN receives three days of training on the west unit and three days of training on the east unit before they were allowed to work the unit by themselves. She said if the nurse was not comfortable after that, they would continue to put them with another nurse until they were comfortable. She said there was a checklist of items the nurse was oriented to that was completed during the floor orientation. -But see below; the schedule for RN #2 revealed she was only oriented to the rehabilitation unit on one night and the floor orientation checklist was not provided prior to the survey exit. b. The DON was interviewed with the NHA on [DATE] at 5:26 p.m. and on [DATE] at 1:45 p.m. The DON said RN #2 had experience working in skilled nursing facilities and had a nursing license. She said RN #2 had received on-the-floor training. She said the facility is not able to provide one-on-one supervision for extended times. 2. Record review A review of RN #2's personnel record revealed she was hired on [DATE]. The schedule for RN #2 was provided by the DON on [DATE] at 2:00 p.m. It revealed RN #2 received orientation to the floor on [DATE], [DATE], and [DATE]. RN #2 began working by herself on the overnight shift on [DATE]. However, the schedule for RN #2 revealed she was only oriented to the rehabilitation unit on one night ([DATE]). The floor orientation checklist was requested for RN #2 on [DATE] but was not received by the end of the survey. B. Resident #2 Resident #2, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included ischemic (lack of blood supply, tissue damage) bowel with right hemicolectomy (removal of part of the colon), history of respiratory failure with hypoxia, and diabetes mellitus. The [DATE] minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. He required extensive two-person assistance with transfers and toileting. He required extensive one-person assistance with bed mobility and dressing and limited two-person assistance with personal hygiene. Resident #2 was on oxygen. A review of the [DATE] physician orders revealed Resident #2 had an order dated [DATE] for oxygen via nasal cannula (NC) at two to three liters per minute (LPM) continuously to keep saturation at or above 90%. Nursing notes reviewed for the week prior to [DATE] revealed Resident #2's oxygen saturation level was consistently in the mid 90's range. On [DATE] it was 94%, on [DATE] it was 94%, on [DATE] it was 93%, and on [DATE] it was 95%. C. Events on [DATE] Record review revealed RN #2 failed to timely assess, monitor, intervene, document, and consult with Resident #2's physician following the resident's change of condition, contributing to Resident #2 sustaining serious harm. 1. Record review The progress notes were reviewed on [DATE]. -On [DATE] at 11:42 p.m., the primary care provider (PCP) documented in pertinent part, that the resident was alert and interactive. His chest sounded clear, his heart had a regular rate and rhythm with no murmur, and his abdominal incision was stable. He further documented he had some elevated blood pressures, and some medications would be discontinued. The PCP documented the resident had peripheral vascular disease, and some of his toes were gangrenous (dead tissue) and may need surgical intervention. The PCP documented, monitor for infection, and ordered some laboratory studies. He documented the resident was deconditioned, on physical and occupational therapy, and had a history of alcohol abuse. The PCP documented Resident #2 was a full cor (full code-CPR). -On [DATE] at 4:13 a.m., RN #2 documented that a certified nurse aide (CNA) was concerned about Resident #2, and asked RN #2 to check on him. RN #2 documented the resident's hands were cold to the touch, and he seemed to be having labored breathing. His oxygen was set at 3.5 liters and his oxygen saturation (O2 sat) reading was 88%. She documented the CNA tried to warm his hands, and his O2 saturation was 95%, but he was still having labored breathing. She raised the head of his bed, and documented will monitor. There was no documentation of physician notification, follow-up assessment, monitoring, or evaluation, and no documentation of further notes by RN #2. -On [DATE] at 6:30 a.m., LPN #1 documented that as she was receiving report when a CNA came to the nurses with a concern that Resident #2 was not doing well. She documented the nurses stopped report and went to assess Resident #2. The note further documented that RN #1 assessed the resident and instructed LPN #1 to call for emergency support, 911. LPN #1 documented that she called 911 at 6:35 a.m. and EMS arrived at the facility by 6:45 a.m. -On [DATE] at 7:02 a.m., RN #1 documented that she was receiving report when a CNA came and said Resident #2 was not doing well. RN #1 documented that she stopped report and went to assess Resident #2. She documented the resident was unresponsive, blood pressure was 151/108, temperature was 97.8, respirations were 6, and his blood sugar was 91. He was on 3.5 LPM of O2. His oxygen saturation was 91%, and his pupils were fixed and dilated. RN #1 documented she could not hear air moving on the right side of his lungs, and on the left side, the breath sounds were diminished. She documented his left and right index fingers were dark in color. RN #1 documented that she stayed with the resident until EMS arrived. -On [DATE] the hospital records documented the resident arrived unresponsive, hypotensive (low blood pressure) and he had to be intubated (breathing tube). His pulse stopped and resuscitation efforts (CPR) were done successfully. The physician documented the cardiac arrest was due to an unknown cause, but could have been due to septic shock with respiratory failure as a result. The physician's notes also documented some possible early pneumonia. The resident was sent to intensive care (ICU) in a critical, unstable condition. The physician documented he had multiple conversations with the family members. He documented the resident was critically ill with cardiac arrest. He told them his prognosis was poor. The family decided to withdraw care, and Resident #2 died on [DATE] at 11:44 a.m. 2. Interviews Staff interviews confirmed RN #2 failed to assess, monitor, intervene, and consult with Resident #2's physician regarding the resident's change of condition, contributing to Resident #2 sustaining serious harm. 1. LPN #1 was interviewed on [DATE] at 12:26 p.m. -LPN #1 said that on [DATE] at around 6:00 a.m., she and RN #1 were getting report from the night nurse, RN #2. CNA #1 came to the three nurses in report and said that Resident #2 was transitioning (first stage, before actively dying). LPN #1 said she was confused because she and RN #1 had worked with Resident #2 the previous day and he was fine. -LPN #1 said RN #1 checked the resident's advance directive and he was a full code. LPN #1 said she and RN #1 went down to the room to assess him. LPN #1 said the resident was barely breathing, his respirations were about 6 breaths per minute, but he was still alive and had a pulse. She said she remembered thinking they were going to have to start CPR. She said RN #1 told her to call 911, which she did, and RN #1 stayed with the resident. -LPN #1 said the night nurse, RN #2, had followed them to the resident's room. RN #2 said she thought this was his baseline, and that he had been like that all night. However, LPN #1 said Resident #2 was normally alert and he was able to make decisions. 2. RN #1 was interviewed on [DATE] at 12:42 p.m. -RN #1 said she came in at 6:00 a.m. for a day shift. She said she and LPN #1 were getting report from the night nurse, RN #2. She said CNA #1 came to the three nurses and said Resident #2 was transitioning. -RN #1 said she was surprised. She said she had just left the facility at 10:30 p.m. after doing an evening shift on [DATE]. She said Resident #2 was a sick man, but alert and oriented, and she had worked with him plenty. She said he had never complained of respiratory distress. -RN #1 said she and LPN #1 went to the resident's room immediately. She said he was gray in color, unresponsive, with respirations at 2 to 3 per minute. She told LPN #1 to call 911, and RN #1 said she stayed with the resident. She said EMS arrived quickly and she followed them out of the facility with him. She said EMS began CPR on him in the facility parking lot before getting him into the ambulance. -RN #1 said RN #2 came down to the resident's room that morning, after a few minutes. She said RN #2 told her the resident had difficulty breathing throughout the night. RN #1 said she told RN #2 that she should have sent the resident out to the hospital. RN #2 responded that she was too busy with paperwork. RN #2 said she had increased his oxygen and raised the head of his bed but then had gotten busy with paperwork and did not reassess the resident. RN #1 said she remembered that RN #2 kept saying the resident had been like that for hours. RN #1 said that she and RN #2 had conversations outside of work, and RN #2 said she was a newer nurse and did not know what to do. -RN #1 said she had expressed her concerns with RN #2 not sending Resident #2 to the hospital to the DON. She said she did not know what follow-up had been done. RN #1 said the ADON asked her to fill out a change of condition Interact (Interventions to Reduce Acute Care Transfers) form, and she told the ADON that she needed to ask RN #2 to do that. 3. RN #2 was interviewed on [DATE] at 2:22 p.m. over the telephone -RN #2 said she remembered Resident #2. She said he was at the facility for rehabilitation and he had a wound vac. RN #2 said one night, she did not recall what time, CNA #1 came and told her Resident #2's oxygen level was low. RN #2 said his oxygen saturation level was 83% and his hands were cold. She said when she grabbed his hand, he grabbed her hand back. She said she raised the head of his bed, and she turned up his oxygen from 3.5 LPM to 4 LPM. RN #2 said the CNA tried to warm his hands and rechecked his oxygen saturation level. It was 95%, but he still had labored breathing. -RN #2 said Resident #2's lungs were clear and his heart sounded good. RN #2 acknowledged she did not document that his heart and lungs sounded good. RN #2 said everything seemed to be within normal limits. RN #2 further acknowledged she did not document his vital signs or complete a change of condition assessment. -RN #2 said she was by herself, and she felt like she did not know what to do. She said it was her first night alone in the rehabilitation unit, and she did not know the residents. RN #2 said she did not think about the fact that it could be a change of condition for Resident #2. She said she should have called the physician, but she did not know the resident or his baseline. She said she did not review his history in the medical record. RN #2 then said his oxygen saturation was not that low at 83%. RN #2 said if it was in the 70s, she would have called the physician. RN #2 said she thought she had listened to his lungs and heart, and they were normal, however, she did not document this. -RN #2 said she asked CNA #1 to check on him throughout the night. She said CNA #1 said she would keep a close eye on the resident and she trusted CNA #1 to do so. She said CNA #1 had to switch halls at some point during the night, but she thought the CNA still came to check on the resident. -RN #2 said the DON called her the next day. She said the DON reassured her and said Resident #2's condition was fragile. RN #2 said she did not recall if the DON asked her about notifying the physician. RN #2 said she told the DON that the CNA was checking on him for her because she had medications she needed to administer. She said, I told the DON I did not check him or assess him again. -RN #2 said at shift change, the CNA came and said the resident did not look good. She said RN #1 sent him to the hospital. RN #2 said she had trusted the CNA to monitor the resident because she was busy by 4:00 a.m. passing medications. She said this was all over her head. She said the reason she did not work at the facility anymore was that she had to work alone, it was a lot of work, and she did not know what to do for Resident #2; this was her first time working with him. 4. CNA #1 was interviewed on [DATE] at 2:38 p.m. -CNA #1 said in the early morning hours on [DATE] she checked Resident #2's oxygen saturation and it was 83% or 88%. She could not remember. She said the nurse (RN #2) came in and turned up his oxygen and his oxygen level went up to 90%. She did not recall if Resident #2 said anything, or if the nurse listened to his lungs. She said that was the first time she worked in the rehabilitation unit and did not know Resident #2. -CNA #1 said she told RN #2 she would check on him again, but her assignment was changed and she did not check on him again until the end of her shift (approximately 6:00 a.m.). She said at that time, he did not look good to her, and she went and told the three nurses in report, the night nurse RN #2, and the two oncoming day nurses, RN #1, and LPN #1. D. Facility response to the events on [DATE] 1. Plan of correction The nursing home administrator (NHA) provided a plan of correction dated [DATE] which was reviewed on [DATE] at 9:30 a.m. The plan read as follows: -100% education of nurses; -Morning meeting review of any change of condition for compliance of notification and documentation; -Monthly review of all change of conditions; and, -Review all change of conditions for trends and opportunity for improvement. 2. In-service and All-staff meeting A review of facility documents revealed the facility completed an in-service on [DATE] and held an all-staff meeting on [DATE] that reviewed changes of condition. Some staff completed the in-service that was located in a binder at the nurses' station, while some nurses attended the all-staff meeting on [DATE]. Records from the meeting showed that all staff either attended or were informed of the contents of the meeting. (Three staff signatures were missing from the [DATE] education but it was confirmed on [DATE] that they were present for the in-service.) On [DATE] at 2:54 p.m., the DON provided the information that was put in the binder for the nurses to sign on [DATE]. There was a one-page typed document. There also was a six-page presentation from the American Association of Post Acute Care Nursing that went into detail on assessment of the body systems, things to look for, and chronic versus acute changes, and then gave scenarios to review and answer questions. On [DATE] at 12:42 p.m., RN #1 said she remembered the DON put an in-service to read and sign in a binder at the nurses' station. She said it was about documentation, and following up on change of condition. She said the in-service was a reminder to the nurses to complete an Interact form (Interventions to Reduce Acute Care Transfers) if there was a change of condition. RN #1 said the nurses were already supposed to be using this form. RN #1 said she remembered reviewing a one-page document in the binder; she did not recall a six-page document regarding changes of condition. She said there were no sample scenarios in the education provided in the binder. 2. Interviews revealed conflicting information on the events on [DATE], as well as potential gaps in the facility's response to events on [DATE] to prevent further failures in the provision of treatment and services. a. The DON was interviewed on [DATE] at 1:21 p.m. and again at 1:39 p.m. -The DON said she had conducted an investigation and it appeared Resident #2 had sepsis. She said she and the nurse managers had spoken to RN #2 about the events on [DATE] but she said she did not speak to CNA #1, RN #1, and LPN #1. She said they looked at the records. The DON said the outcome was not ideal. -The DON said she had looked at the nurse's charting and RN #2 had documented Resident #2 had labored breathing. The DON said she had called RN #2 but did not document her conversation with the nurse. The DON said RN #2 told her she kept an eye on the resident and his breathing was better. -But see above: RN #2 stated she did not check on the resident again until the change of shift. -The DON said she did not think the nurse necessarily needed to document a follow-up assessment or vital signs. She said RN #2 felt the resident was fine; RN #2 had used her clinical judgment and felt Resident #2 was all right and at his baseline, so she was not concerned with her charting. The DON said it was reasonable that the resident was not checked again for two hours until the day shift arrived. -But see above: facility expectations on change of condition and RN #2 interview that she was not aware of Resident #2's baseline status. -The DON said there was an all-staff and nurses meeting on [DATE]. She said she had discussed changes of condition and physician notification in general at the meeting. -But see above: RN #1 said the education was about documentation; a reminder to the nurses to complete an Interact form if there was a change of condition which nurses were already supposed to be using. She did not remember a six-page presentation from the American Association of Post Acute Care Nursing that included scenarios to review and answer questions. -The DON said there was no plan for making sure a situation of a resident with labored breathing and no follow-up, did not happen again. The DON said Resident #2 was sick, he could have (changed condition rapidly) in ten minutes. She agreed, however, that RN #2 should have done a follow-up note and said, without documentation, you can not prove what happened. The DON further said she had not done any follow-up one-to-one education with RN #2, and RN #2 had not attended the [DATE] meeting (but had signed the [DATE] in-service education in the binder.) She further said she should have reached out to the night CNA to find out what she knew about that night. b. The nursing home administrator (NHA) was interviewed on [DATE] at 5:05 p.m. -The NHA said he remembered Resident #2. He said the resident had low oxygen saturations, was monitored throughout the night and went to the hospital in the morning, and later passed away. -But see above: CNA #1 reported she did not go back into Resident #2's room until around 6:00 a.m. and RN #2 reported she did not go back to assess Resident #2 after 4:13 a.m. -He said he had reviewed the situation, and RN #2 could have made better decisions in the moment, as it resulted in a tragic event. In response to a question about follow-up, he said the day nurse did the right thing to send the resident to the hospital. -The NHA said the DON would be the one to investigate a clinical issue. He said she had long conversations with the nurses who were on that day. He said RN #2 could have made better decisions, but he said he was not a clinician and had to trust the clinician. He said RN #2 should have called someone if she did not know what to do. He said he did not know anything else about the situation. -But see above: The DON said she did not interview RN #1, LPN #1, and CNA #1. 4. The DON and NHA were interviewed again on [DATE] at 5:26 p.m. -The DON said this was not a perfect situation but her perspective on the severity of the situation was different and she did not feel the residents were at risk. She said she felt the nurses knew what to do when a change of condition occurred. She said she had done education with them after this situation occurred and she did not feel the nurses needed to be educated again about documenting a change of condition. She said the nurses did not need to do a post-test or any return demonstration to indicate competency or to measure if the information was understood. -The DON said she did not do a competency check with RN #2 or any 1:1 training with her after the situation with Resident #2. The DON said she had concerns with the nurse's charting, and her strength as a nurse. The DON said RN #2 did not feel comfortable working in the rehabilitation unit. She also said the nurse was not comfortable with documentation and said the documentation and the situation could have been better. She said they train staff and put them on the floor and, people make mistakes. The DON said RN #2 thought the resident was okay, and RN #2 felt comfortable with the interventions she had put in place. -The DON said, again, that she educated RN #2 on the phone on [DATE], but she did not have any documentation of what was reviewed, and agreed it was hard to prove the education she had provided since she lacked documentation of it. She said she would write something up regarding their conversation. The DON said this was a documentation issue. She said the facility did investigate the situation, and just did not document it. -But see record review and interviews above: The events on [DATE] involved more than a documentation issue. Record review revealed there was no further assessment, monitoring, interv[TRUNCATED]