**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect a resident from neglect when they failed to recognize a significant decline in condition and accurately assess, treat, and seek progressive emergent treatment in a timely manner for 1 (R1) of 6 residents reviewed for neglect in a sample of 6. These failures resulted in R1 being transferred to a local hospital on 4/12/23, and R1's subsequent death from cardiopulmonary arrest due to or as a consequence of probable gastrointestinal hemorrhage. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 4/12/23, when the facility failed to recognize a significant decline in condition and seek timely emergent medical treatment. V1 (Administrator) was notified of the Immediate Jeopardy on 04/28/23 at 12:35 PM. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 05/02/23, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's face sheet documented an admission date of 11/14/19 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure (CHF), hypertensive heart disease, dementia, weakness, ataxic gait, muscle weakness, cellulitis of right lower limb, Vitamin D deficiency, and chronic kidney disease stage 3. R1's 2/17/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 was cognitively intact. R1's Care Plan dated 11/21/19 includes - Problem Start Date: 05/20/2022. Category: Psychosocial Well-Being. Resident chooses to be a Do Not Resuscitate. Long Term Goal Target Date: 05/18/2023. Resident will inform staff of changes to advance directive. Approach Start Date: 05/20/2022. Code status available for facility staff members. Will follow resident wish and will not attempt to resuscitate. Will review quarterly, annually or with significant change MDS's. Problem Start Date: 11/21/2019. Category: ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential. Res (resident) has Dx (diagnoses) of COPD, CHF, et HTN (and hypertension). Long Term Goal Target Date: 05/18/23. Resident will maintain vital signs within normal limits, perform activities of daily living, and participate in desired activities without evidence of fatigue and/or weakness, breath sounds clear, vital signs within acceptable range, stable weight, no edema. Approach Start Date of 11/21/19 includes: Maintain a sitting/semi-Fowler_positioning, 1:1 (one on one) relaxation techniques, breathing exercises, redirection, O2 (oxygen) , Nebs (nebulizer), Inhalers etc. (other similar things) .as needed during episodes of severe shortness of breath .Monitor and report signs of respiratory distress: (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds) .Monitor for tachycardia, dyspnea, sweating, pale skin color with activity, E.g. (example given); walking, dressing, bathing .Obtain Diagnostic Tests/Labs per MD (medical doctor) orders et (and) notify of abnormalities . R1's record includes a progress note dated 04/11/2023 at 6:36 PM by V10 (Registered Nurse - RN) that documents, Resident noted to have 104 temp (temperature) axillary. PRN (as needed) Tylenol given suppository. NP (V2 - Advanced Practice Registered Nurse/APRN and Director of Nursing/DON) notified. Awaiting further orders. R1's Progress Note dated 04/11/2023 at 9:17 PM by V7 (Licensed Practical Nurse - LPN) documents, Resident resting per recliner. Temp is now 101.2. LCTA Resp E/U (lungs clear to auscultation respirations even/ unlabored). Resident is very slow to respond when spoken to, she keeps her head down while sitting in recliner. Resp are at 32. SPO2 94% (oxygen saturation, percent). R1's record under Vital Signs on 04/11/23 at 9:26 PM/9:27 PM by V14 (Certified Nursing Assistant/CNA) are recorded as: Blood pressure: 91/52, Respirations: 32 (alert triangle with exclamation mark noted), Pulse: 77, and O2 Sat (oxygen saturation): 94%. R1's Progress Note dated 04/12/2023 at 2:31 AM by V7 documents, Resident (R1) had a large loose stool in recliner, on the floor and on resident from head to toe. Both hands coated slathered on fronts of thighs and in her hair. Resident was transferred to w/c (wheelchair) and to shower. Residents temp 100.9, Resp 20, Pulse 64 and regular and SPO2 94%. WCTM (will continue to monitor). Right leg remains bright red and warm to touch. R1's Progress Note dated 04/13/2023 at 6:59 AM by V7 documents, When resident had large loose BM at 2:30 AM 4/12/2023 the stool was thin with undigested food particles noted. Color was an orange, brown color with no noted frank or occult blood. R1's Progress Note dated 04/12/2023 at 2:40 AM by V7 documents, Resident did not speak to staff but could follow staff with eyes. Held onto w/c (wheelchair) and shower chair during transfers. Required max (maximum) assist x 2 (2 staff) with gait belt for transfer. R1's record under Vital Signs, on 04/12/23 at 8:24 AM and recorded by V2, document her pain is assessed as 6 out of 10 and at 11:14 AM, her temperature is 100.1. R1's Progress Note dated 04/12/2023 at 9:39 AM by V2 (APRN/DON) documents, Resident in recliner when passing medications that resident was stupor in recliner and labored breathing. Temp of 102.9. Resident is unresponsive to verbal stimuli however is responsive to painful stimuli of sternal rubs and deep nail press. SPO2 88% on RA (room air). LCTA. Unable to arouse to eat breakfast or take medications PO (by mouth). O2 (oxygen) applied at 3L/min PNC (liters/minute per nasal cannula), Tylenol supp (suppository) given for fever. Cool wash cloths applied to forehead and groin region to decrease temp. Resident was moved to bed out of recliner to perform assessment and treatment. Resident noted with redness, swelling and warmth to RLE (right lower extremity). Cellulitis indicated and resident was given 1-gram Rocephin IM (intramuscularly) x 1 now and then will start Keflex 500 mg (milligram) po tid (three times daily) x 10 days. An Event Report Infection Control Tracker form completed by V2 documents the finding of R1's RLE cellulitis and includes Event Date: 04/12/23 9:26 AM . Classification: Infection Type: Cellulitis/Soft Tissue/Wound. Surveillance Definition Met? McGreers Criteria obv (observation) performed? Yes. Reportable Infection? No. History: Symptoms: Fever, RLE erythema and swelling. Onset Date: 04/12/23. Device Type: No device .Diagnostics (microbiology, other labs, radiology): Diagnostics Performed: No . Treatment: Select which provider ordered testing and treatment: (V2). Order Origin: Nursing Home. Indicate Antibiotic used. If no Antibiotic used, type N/A (not applicable): 04/12/23: Rocephin 1 gram (IM) x 1 now. 04/13/23: Keflex 500 mg po tid x 10 days .Other Information: Was an Event/Observation performed for the related infection? If no, reason needs explained: Yes. Transmission-based Precautions? None. Re-cultured/Assessment Date (if applicable). If yes, indicate date re-tested. NA. Any new orders from re-assessment/culture? If so, indicate new order. NA. Select which provider ordered testing and treatment. (V2) .Additional Information: RLE Cellulitis. Notifications: Attending Faxed: No. Physician Notified: No. Resident Representative Notified: No. Care Plan Reviewed: No. Vitals: Blank. The remainder of this form contains the orders and notes as documented above. R1's record under Vital Signs, on 04/12/23 at 11:14 AM, recorded by V2, documents R1's temperature is 100.1. There were no further recordings of vital signs or documentation of an assessment of R1 in R1's medical record until 04/12/23 at 3:26 PM as documented below. R1's Progress Note dated 04/12/2023 at 3:26 PM by V2 (APRN/DON) documents POA (Power of Attorney/ V3) came to visit resident. Updated POA on current medical condition of resident. Assessed resident while POA in room and noted that resident was in acute respiratory distress. Resident currently on 3L/min PNC, temp is 102.6 prn (as needed). Tylenol supp given at this time. O2 increase to 4L/min. RLE noted to have erythema and swelling and warm to touch, anterior portion erythema has decreased slightly, posterior area unchanged. Mottling noted up to mid-thigh on BLE (bilateral lower extremities). Spoke to POA about changes in condition and explained that sepsis or AKI (acute kidney injury) could be the cause. Resident remains unresponsive to verbal stimuli only has mild responsiveness to sternal rubs. POA states that she would like resident to be evaluated at (name of hospital) however if she has a major issue that she more than likely will not want to do anything. POA chose (name of hospital) to be sent to for evaluation. (Ambulance company) notified and arrived and transferred resident to (hospital). Report was given to V12 (Physician) in the ER (Emergency Room). R1's Prehospital Care Report Summary form from the ambulance company dated 04/12/23 documents that Emergency Medical Services (EMS) arrived at the facility at 2:57 PM after a 911 call from the facility and that R1 was found unresponsive lying-in bed guppy breathing. Staff stated PT (patient/ R1) respirations had been this way all day and they also noticed that PT has cellulitis to the right leg from the ankle to the knee . and Skin looked normal but on the back side of arms and both legs noticed PT looked like her blood was pooling. The form further states Upon arrival at ED (Emergency Department), PT respirations became worse and while cot into room PT went apneic. Ventilations initiated per ED staff. On 4/27/23 at 12:24 PM, V6 (Paramedic) stated he arrived at the facility on 4/12/23 and found R1 to be lying in bed guppy breathing and unresponsive. V6 said facility staff told him R1 had been guppy breathing like this on and off all day. V6 stated just by the way (R1) was breathing I knew she was not going to last long. V6 said the back side of R1's arms and legs had dark discoloration which looked like blood was pooling, like how blood pools in the skin at the lowest point after a person expires. V6 said R1 stopped breathing as they were going through the ED doors. R1's progress note dated 04/12/2023 at 6:05 PM by V2 documents, Received phone call from V12 (Physician) at (hospital ER). MD (Medical Doctor) states that resident arrived at ER and coded. Attempted to intubate and noticed resident had aspirated on blood. MD states that resident had a massive GI (gastrointestinal) bleed and was DNI (do not intubate) and DNR (do not resuscitate) and resident expired in ER. V4 (Medical Director), V1 (Administrator) aware. V3 at facility when resident expired. R1's hospital ED Physician Documentation dated 4/12/23 at 3:38 PM by V12 documents Patient (R1) was brought in by (ambulance company) with no spontaneous respirations, but an irregular heartbeat. (R1) is DNR/ DNI. (R1) was evidencing black emesis from the mouth and she was full in both lungs of black fluid that appeared to be from a GI bleed. R1 expired fully at 3:49 PM today (4/12/23). R1's Death Certificate documents date of death was 04/12/23. The Cause of Death documents: a. Cardiopulmonary Arrest, due to (or as a consequence of) b. Probable Gastrointestinal Hemorrhage. On 4/27/23 at 9:26 AM, V3 (POA) confirmed R1 was not receiving services of hospice or comfort care measures. V3 said she had never told the facility she did not want R1 sent to the hospital if it was medically needed. V3 said R1 was a 'Do Not Resuscitate' but V3 still expected the facility to treat R1. V3 said R1 was alert and oriented on 4/9/23. R1's State of Illinois, Illinois Department of Public Health - IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form documents in Section A Cardiopulmonary Resuscitation (CPR), If patient has no pulse and is not breathing, the option of Do Not Attempt Resuscitation (DNR) is selected. Section B Medical Interventions, if patient is found with a pulse and/or is breathing the option of Comfort-Focused Treatment is selected and defined as follows: Primary goal of maximizing comfort. Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. V3 signed R1's POLST form as her Legal Representative and V2 (APRN/DON) signed as the Authorized Practitioner and both dated 11/14/19. On 4/27/23 at 10:31 AM, V2 (APRN/DON) said he assessed R1 on 4/12/23 in the morning and found R1 was unresponsive and was transferred from the recliner to bed. V2 said R1 was febrile and V2 ordered a Tylenol suppository, Rocephin, and Keflex. V2 said R1 was mainly unresponsive most of the day. V2 said R1's oxygen saturation dropping was not normal for R1 and oxygen was applied. V2 said he did not contact V3 (POA) because V3 had the facility number blocked so R1 could not call V3 during the night. V2 said the facility would text V3 if they needed to report any change in condition. V2 said he did not attempt to contact V3 in any way because V2 did not think R1's change in condition was serious enough to contact V3. V2 said when V3 arrived at the facility, V2 updated V3 on R1's change in condition. V2 said he asked V3 if they wanted R1 to be transferred to the hospital or if they wanted R1 to stay in the facility and keep R1 comfortable. V2 said V3 chose to send R1 to the hospital. V2 said R1 was not under hospice services and was not on comfort care. When V2 was asked if R1 being so unresponsive that R1 could not take medications by mouth and had to have a Tylenol suppository was concerning, V2 said the fever was concerning, that is why I was treating her. On 05/02/23 at 10:25 AM, a follow-up interview was conducted with V3 (POA). V3 was asked to recount and confirm the events on 04/12/23 regarding R1. V3 stated she was there that day because the grandkids had sent some pictures and she wanted to put them in frames and do some decorating in R1's room. V3 added that the whole family had just been in the facility on Easter Sunday (04/09/23) and ate dinner together with R1. V3 stated, My brother and everyone got to see her, so everyone saw her in great condition and she was able to visit. She was perfectly cognitive that Sunday. V3 continued that when she arrived in the facility on the afternoon of 04/12/23, V2 caught her up on what had been happening with R1 from the night before and wanted to prepare her. When this surveyor asked what that meant, V3 stated she was not sure exactly what he meant. V3 stated V2 told her it had been a couple of hours since he had last checked on R1 so they both had gone to her room at that time. V3 stated she felt blindsided. V3 said that R1 was not in her regular room, but in another room across the hall. V3 stated she observed R1 lying flat in a bed with no oxygen on her nose, nor did she observe any oxygen in the room. V3 stated, I don't know how long (R1) had been lying in bed, but (V2) just said the night before she had run a fever, was still running a fever that day, and had been given a shot and antibiotic. (R1) did not have a bed in her regular room because she sleeps in a recliner because of her COPD. She had slept in a chair forever. (R1) was observed to be non-responsive, so V2 tried doing a sternal rub. (R1) did not respond. V2 looked at R1's legs and he saw the mottling in her lower legs and told me 'that concerned him'. V3 stated that V2 told her, It just has me baffled. I don't know what more to do because most of her vital signs were good. V3 stated that it was not clear to V2 what he was dealing with, and at that point V3 said, I think we need to send her to the hospital and that maybe it was something an IV could take care of. If it was not something the ER could stabilize, I would have gone from there and discussed comfort care if nothing else would have worked at that time. When asked if she had spoken to the hospital yet, she (V3) stated, Not really, I was told she had passed in the ambulance. She had thrown up some black tarry vomit and had a major gastric bleed. The ER doctor did tell me that. A few years ago, she (R1) was in another hospital for a gastric bleed. That was another thing that raised questions for me because she had COPD and a history of gastric bleed, and I didn't receive a phone call from anyone in the facility prior to me walking in on 04/12/23. When asked if V3 had any of her phone numbers blocked so the facility would be unable to contact her, V3 stated, I did not have my phone off and my phone number is not blocked to receive calls from the facility. A lot of times I may not hear the ringer or may not have my phone on me but if I had missed a call, I'd have seen that and would have called back immediately. I have missed calls before and I always return their call. I have phone records to show there were no missed calls from the facility on 04/11/23 or 04/12/23. When asked about receiving texts, V3 stated she had received texts in the past from V2. On 4/27/23 at 9:50 AM, V4 (Medical Director/Physician) said if a resident was found to be febrile, unresponsive to verbal stimuli, and have labored breathing with an oxygen saturation in the 80's he expected the facility would contact V4. V4 said if it is a serious problem the resident should be transferred to the hospital. V4 said he expected the facility to notify a resident's POA with any change in condition. V4 said it is possible if R1 was transferred to the hospital six hours earlier, when symptom onset began, R1 may not have expired. On 04/28/23 at 3:24 PM, V4 was contacted for a second interview. V4 stated that a resident's condition certainly changes, and they should be taken care of appropriately. Sometimes the patient and the family change their mind or direction they are going when they sign the POLST originally, but there should be a clear understanding from the patient and family of what treatment they want. When asked if DNR meant do not treat, V4 confirmed it means, Do Not Resuscitate, adding the patient should always be taken care of regarding their symptoms or whatever is happening. When asked if on 04/12/23, the emergency room could have provided any further or different treatment than R1 had already been provided at the facility, V4 stated when you go to the hospital, they do everything so they can find out what is going on. An additional document with the State of Illinois, Illinois Department of Public Health seal titled Illinois Statutory Short Form Power of Attorney for Health Care documents that R1 wants (V3) to be her health care agent. The form further documents, I authorize my agent to with the box checked Make decisions for me starting now and continue after I am no longer able to make them for myself. While I am still able to make my own decisions, I can still do so if I want to. Under Life-Sustaining Treatments documents, in part . In general, in making decisions concerning life-sustaining treatment, your agent is instructed to consider the relief of suffering, the quality as well as the possible extension of your life, and your previously expressed wishes. Your agent will weigh the burdens versus benefits of proposed treatments in making decisions on your behalf. On 05/02/23 at 3:05 PM, V2 (APRN/DON), V9 (Chief Executive Officer/CEO), and V1 (Administrator) entered the conference room where this surveyor was working. V2 again stated he had not been given the chance to report the events that transpired throughout the day on 04/12/23 regarding R1's condition. V2 was asked if he had any new information he would like to provide at this time. V2 stated when he got to R1's room on 04/12/23 to pass medication at approximately 7:30 AM, she was sitting up in her recliner with her chin down to her chest. V2 stated he did notice she looked uncomfortable at that time stating R1 was stupor and not as alert. V2 stated, I did a sternal rub on her. She did wake up and look at me. Then, I asked her if she was hurting. She did not respond to that. At that point, we moved her from the recliner to the bed in a room across the hall. V2 stated once R1 was in bed her vital signs were checked. R1's oxygen saturation was about 88/89%, so she was placed on oxygen via nasal cannula at 2 liters and the head of her bed was elevated to 45 degrees. V2 stated, While I was in there, I assessed her by listening to her lungs which were clear and I checked her skin. I did see that her right lower extremity had some redness, swelling, and was warm to the touch and she had a fever of 102 degrees. V2 stated at that point he gave R1 a Tylenol suppository and an injection of Rocephin. V2 stated he placed cool wash clothes on her forehead, armpits, and groin and from there made the decision not to give her any oral intake due to the risk of aspiration. V2 stated R1 was peaceful and comfortable at this time. V2 stated that after R1 was settled, he went to the nursing station and continued with nursing duties. He did attempt to call R1's POA (V3) but it only rang once and the call was disconnected. V2 stated normally if she saw we called, she would call back or come in. V2 stated, It could be minutes, hours, or days before you would get a response. V2 stated at 9:30 AM, he checked on R1 again, removed the wash cloths, but did not check her temperature because it would not have given a correct reading. V2 stated R1 had no rapid breathing, nothing appeared abnormal, and R1 displayed no signs or symptoms of pain. V2 stated he did not attempt to wake R1 at that time opting to let her rest. V2 stated that he went back at 11:00 AM, rechecked her temperature and it was 101 degrees. He did try to wake her by speaking to her but she did not wake up. V2 stated he did another sternal rub and R1 did wake up, open her eyes, and groaned slightly. V2 stated R1's lungs were still clear at that time, she had no symptoms of respiratory distress, and her color was good. V2 stated he asked the CNAs if they would attempt to feed her at lunch and they reported back to him that R1 did not eat lunch. V2 stated the CNAs checked on R1 around noon, then V2 went back down around 2:30 PM when V3 showed up to visit R1. V2 stated he assessed R1 with V3 present, and her fever was 102 degrees. V2 stated he administered another Tylenol suppository and explained that R1 had cellulitis that could be causing the fever. V2 stated V3 tried to wake R1 up herself by repeating her name and when she did that, R1 started breathing heavier and more labored than what she had been previously. V2 stated he explained the options of keeping R1 in the facility would be to keep her comfortable, pain free, and without respiratory distress or they could send her to the ER and see if there was anything else that was going on they might be able to fix. V2 stated, V3 asked him what he thought, and he told V3 it was her decision, and that V2 could do either. V2 stated, I could start her on Morphine/Ativan or send her to the hospital. V3 then asked which hospital she should go to. V2 again told V3 that was her decision. V2 stated R1 did not appear critical at that time, so it was up to V3. V2 stated that V3 opted to send R1 to the hospital, claiming that the family would be mad at her if she didn't send R1 to the hospital. V2 stated V3 then said if they find anything serious, she was not going to do anything. V2 then told V3 he would call EMS and have her sent. V2 stated V3 asked him if she had to be there and he again told V3 that it was up to her but he would give report to the ER. V2 stated V3 left at that time, EMS arrived and did not do an in-room assessment - just got report from him. V2 stated, R1 was loaded on the stretcher and was in their hands after that. V2 stated he gave report to V12 in the ER. V12 called back about an hour later and explained to V2 that R1 had passed .that she coded when she came through the ER doors, (V12) attempted to intubate but saw what appeared to be aspiration of blood and assumed she had a massive GI bleed. They witnessed the POLST form DNR and did not proceed with intubation nor any further treatment. On 05/02/23 at 3:30 PM, V9 (Chief Executive Officer/CEO/Social Services) stated V3 came by the next day to get R1's belongings and praised the facility for the care of R1. V9 had with him the IDPH printout titled, Guidance Document for Illinois Health Care Professionals and Providers - Illinois Department of Public Health (IDPH) Uniform Practitioner Orders for Life-Sustaining Treatment and stated he wanted to go over the parts he highlighted. V9 then read from Page 2 of this document - healthcare professionals and institutional providers are legally protected from liability if, in good faith they honor the instructions contained in the POLST form . V9 stated, Which is exactly what we did. V9 stated R1's POLST indicated she was comfort focused treatment. V9 stated, This is the big one, and read the following from the document - Transfer to hospital only if comfort cannot be achieved in the comfort setting . V9 stated, We were going by what was on her POLST .I think we were within our guidelines and it's cut and dry we were following the resident's wishes. V9 read, POLST portable medical orders form, signed by the patient's qualified healthcare practitioner and either the patient or their legal representative, converts the patient's care choices into an actionable medical order that all other physicians, nurse practitioners, physicians assistants, long-term care facilities, hospices, home health agencies, emergency medical services, hospital staff, and other provider staff are required by law to honor . V9 also read, .the POLST model allows individuals to specify the intensity of medical interventions when they experience a life-threatening emergency where they still have a pulse. On 05/02/23 at 3:45 PM, V2 stated he believes the facility did everything as they should have and provided the care and comfort to R1 she required prior to her being transferred to the ER on [DATE]. When asked if V2 had anything else he would like to add to his interview, he stated, I stand beside the treatment R1 received in the facility on 04/11/23 and 04/12/23. If I had to do it over, I would do the same thing. I wouldn't change anything. An email correspondence from V1 (Administrator) dated 5/1/23 at 1:43pm documents that (V2) is a full practice NP (Nurse Practitioner) in response to the question if V2 has a collaborating agreement with a physician or if V2 has a full practice authority license. This email also contained V2's license that documents Full Practice Authority APRN. The facility's 11/12/22 Notification of Changes in Condition policy documented in part . The facility must inform . the resident's family member or legal representative when there is a change requiring such notification. Circumstance requiring notification include: 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status . 3. Circumstances that require a need to alter treatment . According to https://www.polstil.org/resources-for-healthcare-providers/, the Guidance Document for Healthcare Professionals documents the following in part . POLST stands for 'Practitioner Orders for Life-Sustaining Treatment.' A POLST form is a signed medical order that travels with the patient to assure that a patient's treatment preferences are honored across settings of care. The POLST form is designed to ensure that seriously ill or frail patients can choose the treatments they want or do not want and that their wishes are documented and honored Use of the POLST form is voluntary. This form contains orders that can be revoked or changed at any time by patients or their legal representative When a patient's condition changes significantly, prior decisions about treatment should be revisited and consideration should be given to completing a new, updated POLST form. On 05/04/23 at 8:23 AM, V15 (LPN) stated prior to R1's fever the evening of 04/11/23, she did not appear to have anything going on. V15 stated, It seemed like it came out of nowhere. It seemed like it happened very quickly. V15 stated R1 would propel through the facility in her wheelchair but did stay in her room quite a bit. She was not able to ambulate or stand/transfer on her own but once she was in the wheelchair she could propel independently where she wanted to go. On 05/04/23 at 9:07 AM, V16 (CNA) and V8 (CNA) both stated normally R1 was awake and alert but sometimes she would get sleepy and tell us she just wanted to sleep. She had a habit of staying up at night sometimes and going through the drawers/packing her things to go home. V16 stated they would have to check the schedule but the last time they worked, R1 was fine. V8 stated the last time she worked and saw R1 was on 04/11/23 between 6:30 AM and 3:00 PM. V8 stated R1 had a shower that day and was tired after and wanted to sleep. V8 stated R1 slept in her recliner. V8 stated she did work the same shift on 04/12/23 but was not really involved with R1's care that day. However, there was nothing observed that would have given an indication R1 needed to be sent out to the hospital. She just knows she was sent out to the hospital and was surprised to hear she passed away. On 05/04/23 at 11:03 AM, V10 (RN) stated she did work on 04/11/23 from 2:30 PM to 7:00 PM. V10 was asked about R1's condition that day. V10 stated, I remember she started running a fever when I was getting ready to leave between 6:15 PM and 6:30 PM that evening. I gave her a Tylenol suppository and called (V2/APRN) to report the fever and lethargy and he said he would follow-up with (R1) the next morning. V10 stated R1 had episodes of lethargy in the past where she would look at you but would not speak. V10 reported they sent R1 to the hospital for a similar episode in the past and R1 told the hospital staff she just didn't want to talk to us and wanted to be left alone so she could sleep. V10 confirmed on 04/11/23, R1 did have redness to her legs, however, R1 had intermittent edema/cellulitis in her legs in the past that had been treated with steroid creams and wraps/socks. At times, it was cellulitis, but R1 did have chronic dermatitis. V10 stated, It was not too alarming at that point. I gave the night nurse the report and asked her to monitor R1. At that point, she just had a fever and was not verbalizing, so I thought it was like her past behavior. On 05/04/23 at 11:27 AM, V7 (LPN) stated it was normal for R1 to be incontinent. When asked about the events of her shift on 04/11/23, V7 stated, On 04/11/23, she did not want to get up and get in the shower, but she had been incontinent and had feces everywhere. She would not talk to us; she would glare at us and hold on for dear life to anything she could get a hold of. She would do the same thing to the CNAs in the past when they tried to get her up if she had been incontinent in her recliner through the night. V7 stated that R1 had been running a fever earlier in the day on 04/11/23 and received report it was coming down. V7 stated she kept checking R1's temperature and it was going down. V7 stated there was really no change in R1's condition from when she arrived to when her shift ended on 04/[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to recognize a significant decline in condition and accurately assess, treat, and seek progressive emergent treatment in a timely manner for 1 (R1) of 6 residents reviewed for change in condition in a sample of 6. These failures resulted in R1 being transferred to a local hospital on 4/12/23, and R1's subsequent death from cardiopulmonary arrest due to or as a consequence of a probable gastrointestinal hemorrhage. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 4/12/23, when the facility failed to recognize a significant decline in condition and seek timely emergent medical treatment. V1 (Administrator) was notified of the Immediate Jeopardy on 04/28/23 at 12:35 PM. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 05/02/23, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's face sheet documented an admission date of 11/14/19 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure (CHF), hypertensive heart disease, dementia, weakness, ataxic gait, muscle weakness, cellulitis of right lower limb, Vitamin D deficiency, and chronic kidney disease stage 3. R1's 2/17/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 was cognitively intact. R1's Care Plan dated 11/21/19 includes - Problem Start Date: 05/20/2022. Category: Psychosocial Well-Being. Resident chooses to be a Do Not Resuscitate. Long Term Goal Target Date: 05/18/2023. Resident will inform staff of changes to advance directive. Approach Start Date: 05/20/2022. Code status available for facility staff members. Will follow resident wish and will not attempt to resuscitate. Will review quarterly, annually or with significant change MDS's. Problem Start Date: 11/21/2019. Category: ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential. Res (resident) has Dx (diagnoses) of COPD, CHF, et HTN (and hypertension). Long Term Goal Target Date: 05/18/23. Resident will maintain vital signs within normal limits, perform activities of daily living, and participate in desired activities without evidence of fatigue and/or weakness, breath sounds clear, vital signs within acceptable range, stable weight, no edema. Approach Start Date of 11/21/19 includes: Maintain a sitting/semi-Fowler_positioning, 1:1 (one on one) relaxation techniques, breathing exercises, redirection, O2 (oxygen) , Nebs (nebulizer), Inhalers etc. (other similar things) .as needed during episodes of severe shortness of breath .Monitor and report signs of respiratory distress: (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds) .Monitor for tachycardia, dyspnea, sweating, pale skin color with activity, E.g. (example given); walking, dressing, bathing .Obtain Diagnostic Tests/Labs per MD (medical doctor) orders et (and) notify of abnormalities . R1's record includes a progress note dated 04/11/2023 at 6:36 PM by V10 (Registered Nurse - RN) that documents, Resident noted to have 104 temp (temperature) axillary. PRN (as needed) Tylenol given suppository. NP (V2 - Advanced Practice Registered Nurse/APRN and Director of Nursing/DON) notified. Awaiting further orders. R1's Progress Note dated 04/11/2023 at 9:17 PM by V7 (Licensed Practical Nurse - LPN) documents, Resident resting per recliner. Temp is now 101.2. LCTA Resp E/U (lungs clear to auscultation respirations even/ unlabored). Resident is very slow to respond when spoken to, she keeps her head down while sitting in recliner. Resp are at 32. SPO2 94% (oxygen saturation, percent). R1's record under Vital Signs on 04/11/23 at 9:26 PM/9:27 PM by V14 (Certified Nursing Assistant/CNA) are recorded as: Blood pressure: 91/52, Respirations: 32 (alert triangle with exclamation mark noted), Pulse: 77, and O2 Sat (oxygen saturation): 94%. R1's Progress Note dated 04/12/2023 at 2:31 AM by V7 documents, Resident (R1) had a large loose stool in recliner, on the floor and on resident from head to toe. Both hands coated slathered on fronts of thighs and in her hair. Resident was transferred to w/c (wheelchair) and to shower. Residents temp 100.9, Resp 20, Pulse 64 and regular and SPO2 94%. WCTM (will continue to monitor). Right leg remains bright red and warm to touch. R1's Progress Note dated 04/13/2023 at 6:59 AM by V7 documents, When resident had large loose BM at 2:30 AM 4/12/2023 the stool was thin with undigested food particles noted. Color was an orange, brown color with no noted frank or occult blood. R1's Progress Note dated 04/12/2023 at 2:40 AM by V7 documents, Resident did not speak to staff but could follow staff with eyes. Held onto w/c (wheelchair) and shower chair during transfers. Required max (maximum) assist x 2 (2 staff) with gait belt for transfer. R1's record under Vital Signs, on 04/12/23 at 8:24 AM and recorded by V2, document her pain is assessed as 6 out of 10 and at 11:14 AM, her temperature is 100.1. R1's Progress Note dated 04/12/2023 at 9:39 AM by V2 (APRN/DON) documents, Resident in recliner when passing medications that resident was stupor in recliner and labored breathing. Temp of 102.9. Resident is unresponsive to verbal stimuli however is responsive to painful stimuli of sternal rubs and deep nail press. SPO2 88% on RA (room air). LCTA. Unable to arouse to eat breakfast or take medications PO (by mouth). O2 (oxygen) applied at 3L/min PNC (liters/minute per nasal cannula), Tylenol supp (suppository) given for fever. Cool wash cloths applied to forehead and groin region to decrease temp. Resident was moved to bed out of recliner to perform assessment and treatment. Resident noted with redness, swelling and warmth to RLE (right lower extremity). Cellulitis indicated and resident was given 1-gram Rocephin IM (intramuscularly) x 1 now and then will start Keflex 500 mg (milligram) po tid (three times daily) x 10 days. An Event Report Infection Control Tracker form completed by V2 documents the finding of R1's RLE cellulitis and includes Event Date: 04/12/23 9:26 AM . Classification: Infection Type: Cellulitis/Soft Tissue/Wound. Surveillance Definition Met? McGreers Criteria obv (observation) performed? Yes. Reportable Infection? No. History: Symptoms: Fever, RLE erythema and swelling. Onset Date: 04/12/23. Device Type: No device .Diagnostics (microbiology, other labs, radiology): Diagnostics Performed: No . Treatment: Select which provider ordered testing and treatment: (V2). Order Origin: Nursing Home. Indicate Antibiotic used. If no Antibiotic used, type N/A (not applicable): 04/12/23: Rocephin 1 gram (IM) x 1 now. 04/13/23: Keflex 500 mg po tid x 10 days .Other Information: Was an Event/Observation performed for the related infection? If no, reason needs explained: Yes. Transmission-based Precautions? None. Re-cultured/Assessment Date (if applicable). If yes, indicate date re-tested. NA. Any new orders from re-assessment/culture? If so, indicate new order. NA. Select which provider ordered testing and treatment. (V2) .Additional Information: RLE Cellulitis. Notifications: Attending Faxed: No. Physician Notified: No. Resident Representative Notified: No. Care Plan Reviewed: No. Vitals: Blank. The remainder of this form contains the orders and notes as documented above. R1's record under Vital Signs, on 04/12/23 at 11:14 AM, recorded by V2, documents R1's temperature is 100.1. There were no further recordings of vital signs or documentation of an assessment of R1 in R1's medical record until 04/12/23 at 3:26 PM as documented below. R1's Progress Note dated 04/12/2023 at 3:26 PM by V2 (APRN/DON) documents POA (Power of Attorney/ V3) came to visit resident. Updated POA on current medical condition of resident. Assessed resident while POA in room and noted that resident was in acute respiratory distress. Resident currently on 3L/min PNC, temp is 102.6 prn (as needed). Tylenol supp given at this time. O2 increase to 4L/min. RLE noted to have erythema and swelling and warm to touch, anterior portion erythema has decreased slightly, posterior area unchanged. Mottling noted up to mid-thigh on BLE (bilateral lower extremities). Spoke to POA about changes in condition and explained that sepsis or AKI (acute kidney injury) could be the cause. Resident remains unresponsive to verbal stimuli only has mild responsiveness to sternal rubs. POA states that she would like resident to be evaluated at (name of hospital) however if she has a major issue that she more than likely will not want to do anything. POA chose (name of hospital) to be sent to for evaluation. (Ambulance company) notified and arrived and transferred resident to (hospital). Report was given to V12 (Physician) in the ER (Emergency Room). R1's Prehospital Care Report Summary form from the ambulance company dated 04/12/23 documents that Emergency Medical Services (EMS) arrived at the facility at 2:57 PM after a 911 call from the facility and that R1 was found unresponsive lying-in bed guppy breathing. Staff stated PT (patient/ R1) respirations had been this way all day and they also noticed that PT has cellulitis to the right leg from the ankle to the knee . and Skin looked normal but on the back side of arms and both legs noticed PT looked like her blood was pooling. The form further states Upon arrival at ED (Emergency Department), PT respirations became worse and while cot into room PT went apneic. Ventilations initiated per ED staff. On 4/27/23 at 12:24 PM, V6 (Paramedic) stated he arrived at the facility on 4/12/23 and found R1 to be lying in bed guppy breathing and unresponsive. V6 said facility staff told him R1 had been guppy breathing like this on and off all day. V6 stated just by the way (R1) was breathing I knew she was not going to last long. V6 said the back side of R1's arms and legs had dark discoloration which looked like blood was pooling, like how blood pools in the skin at the lowest point after a person expires. V6 said R1 stopped breathing as they were going through the ED doors. R1's progress note dated 04/12/2023 at 6:05 PM by V2 documents, Received phone call from V12 (Physician) at (hospital ER). MD (Medical Doctor) states that resident arrived at ER and coded. Attempted to intubate and noticed resident had aspirated on blood. MD states that resident had a massive GI (gastrointestinal) bleed and was DNI (do not intubate) and DNR (do not resuscitate) and resident expired in ER. V4 (Medical Director), V1 (Administrator) aware. V3 at facility when resident expired. R1's hospital ED Physician Documentation dated 4/12/23 at 3:38 PM by V12 documents Patient (R1) was brought in by (ambulance company) with no spontaneous respirations, but an irregular heartbeat. (R1) is DNR/ DNI. (R1) was evidencing black emesis from the mouth and she was full in both lungs of black fluid that appeared to be from a GI bleed. R1 expired fully at 3:49 PM today (4/12/23). R1's Death Certificate documents date of death was 04/12/23. The Cause of Death documents: a. Cardiopulmonary Arrest, due to (or as a consequence of) b. Probable Gastrointestinal Hemorrhage. On 4/27/23 at 9:26 AM, V3 (POA) confirmed R1 was not receiving services of hospice or comfort care measures. V3 said she had never told the facility she did not want R1 sent to the hospital if it was medically needed. V3 said R1 was a 'Do Not Resuscitate' but V3 still expected the facility to treat R1. V3 said R1 was alert and oriented on 4/9/23. R1's State of Illinois, Illinois Department of Public Health - IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form documents in Section A Cardiopulmonary Resuscitation (CPR), If patient has no pulse and is not breathing, the option of Do Not Attempt Resuscitation (DNR) is selected. Section B Medical Interventions, if patient is found with a pulse and/or is breathing the option of Comfort-Focused Treatment is selected and defined as follows: Primary goal of maximizing comfort. Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. V3 signed R1's POLST form as her Legal Representative and V2 (APRN/DON) signed as the Authorized Practitioner and both dated 11/14/19. On 4/27/23 at 10:31 AM, V2 (APRN/DON) said he assessed R1 on 4/12/23 in the morning and found R1 was unresponsive and was transferred from the recliner to bed. V2 said R1 was febrile and V2 ordered a Tylenol suppository, Rocephin, and Keflex. V2 said R1 was mainly unresponsive most of the day. V2 said R1's oxygen saturation dropping was not normal for R1 and oxygen was applied. V2 said he did not contact V3 (POA) because V3 had the facility number blocked so R1 could not call V3 during the night. V2 said the facility would text V3 if they needed to report any change in condition. V2 said he did not attempt to contact V3 in any way because V2 did not think R1's change in condition was serious enough to contact V3. V2 said when V3 arrived at the facility, V2 updated V3 on R1's change in condition. V2 said he asked V3 if they wanted R1 to be transferred to the hospital or if they wanted R1 to stay in the facility and keep R1 comfortable. V2 said V3 chose to send R1 to the hospital. V2 said R1 was not under hospice services and was not on comfort care. When V2 was asked if R1 being so unresponsive that R1 could not take medications by mouth and had to have a Tylenol suppository was concerning, V2 said the fever was concerning, that is why I was treating her. On 05/02/23 at 10:25 AM, a follow-up interview was conducted with V3 (POA). V3 was asked to recount and confirm the events on 04/12/23 regarding R1. V3 stated she was there that day because the grandkids had sent some pictures and she wanted to put them in frames and do some decorating in R1's room. V3 added that the whole family had just been in the facility on Easter Sunday (04/09/23) and ate dinner together with R1. V3 stated, My brother and everyone got to see her, so everyone saw her in great condition and she was able to visit. She was perfectly cognitive that Sunday. V3 continued that when she arrived in the facility on the afternoon of 04/12/23, V2 caught her up on what had been happening with R1 from the night before and wanted to prepare her. When this surveyor asked what that meant, V3 stated she was not sure exactly what he meant. V3 stated V2 told her it had been a couple of hours since he had last checked on R1 so they both had gone to her room at that time. V3 stated she felt blindsided. V3 said that R1 was not in her regular room, but in another room across the hall. V3 stated she observed R1 lying flat in a bed with no oxygen on her nose, nor did she observe any oxygen in the room. V3 stated, I don't know how long (R1) had been lying in bed, but (V2) just said the night before she had run a fever, was still running a fever that day, and had been given a shot and antibiotic. (R1) did not have a bed in her regular room because she sleeps in a recliner because of her COPD. She had slept in a chair forever. (R1) was observed to be non-responsive, so V2 tried doing a sternal rub. (R1) did not respond. V2 looked at R1's legs and he saw the mottling in her lower legs and told me 'that concerned him'. V3 stated that V2 told her, It just has me baffled. I don't know what more to do because most of her vital signs were good. V3 stated that it was not clear to V2 what he was dealing with, and at that point V3 said, I think we need to send her to the hospital and that maybe it was something an IV could take care of. If it was not something the ER could stabilize, I would have gone from there and discussed comfort care if nothing else would have worked at that time. When asked if she had spoken to the hospital yet, she (V3) stated, Not really, I was told she had passed in the ambulance. She had thrown up some black tarry vomit and had a major gastric bleed. The ER doctor did tell me that. A few years ago, she (R1) was in another hospital for a gastric bleed. That was another thing that raised questions for me because she had COPD and a history of gastric bleed, and I didn't receive a phone call from anyone in the facility prior to me walking in on 04/12/23. When asked if V3 had any of her phone numbers blocked so the facility would be unable to contact her, V3 stated, I did not have my phone off and my phone number is not blocked to receive calls from the facility. A lot of times I may not hear the ringer or may not have my phone on me but if I had missed a call, I'd have seen that and would have called back immediately. I have missed calls before and I always return their call. I have phone records to show there were no missed calls from the facility on 04/11/23 or 04/12/23. When asked about receiving texts, V3 stated she had received texts in the past from V2. On 4/27/23 at 9:50 AM, V4 (Medical Director/Physician) said if a resident was found to be febrile, unresponsive to verbal stimuli, and have labored breathing with an oxygen saturation in the 80's he expected the facility would contact V4. V4 said if it is a serious problem the resident should be transferred to the hospital. V4 said he expected the facility to notify a resident's POA with any change in condition. V4 said it is possible if R1 was transferred to the hospital six hours earlier, when symptom onset began, R1 may not have expired. On 04/28/23 at 3:24 PM, V4 was contacted for a second interview. V4 stated that a resident's condition certainly changes, and they should be taken care of appropriately. Sometimes the patient and the family change their mind or direction they are going when they sign the POLST originally, but there should be a clear understanding from the patient and family of what treatment they want. When asked if DNR meant do not treat, V4 confirmed it means, Do Not Resuscitate, adding the patient should always be taken care of regarding their symptoms or whatever is happening. When asked if on 04/12/23, the emergency room could have provided any further or different treatment than R1 had already been provided at the facility, V4 stated when you go to the hospital, they do everything so they can find out what is going on. An additional document with the State of Illinois, Illinois Department of Public Health seal titled Illinois Statutory Short Form Power of Attorney for Health Care documents that R1 wants (V3) to be her health care agent. The form further documents, I authorize my agent to with the box checked Make decisions for me starting now and continue after I am no longer able to make them for myself. While I am still able to make my own decisions, I can still do so if I want to. Under Life-Sustaining Treatments documents, in part . In general, in making decisions concerning life-sustaining treatment, your agent is instructed to consider the relief of suffering, the quality as well as the possible extension of your life, and your previously expressed wishes. Your agent will weigh the burdens versus benefits of proposed treatments in making decisions on your behalf. On 05/02/23 at 3:05 PM, V2 (APRN/DON), V9 (Chief Executive Officer/CEO), and V1 (Administrator) entered the conference room where this surveyor was working. V2 again stated he had not been given the chance to report the events that transpired throughout the day on 04/12/23 regarding R1's condition. V2 was asked if he had any new information he would like to provide at this time. V2 stated when he got to R1's room on 04/12/23 to pass medication at approximately 7:30 AM, she was sitting up in her recliner with her chin down to her chest. V2 stated he did notice she looked uncomfortable at that time stating R1 was stupor and not as alert. V2 stated, I did a sternal rub on her. She did wake up and look at me. Then, I asked her if she was hurting. She did not respond to that. At that point, we moved her from the recliner to the bed in a room across the hall. V2 stated once R1 was in bed her vital signs were checked. R1's oxygen saturation was about 88/89%, so she was placed on oxygen via nasal cannula at 2 liters and the head of her bed was elevated to 45 degrees. V2 stated, While I was in there, I assessed her by listening to her lungs which were clear and I checked her skin. I did see that her right lower extremity had some redness, swelling, and was warm to the touch and she had a fever of 102 degrees. V2 stated at that point he gave R1 a Tylenol suppository and an injection of Rocephin. V2 stated he placed cool wash clothes on her forehead, armpits, and groin and from there made the decision not to give her any oral intake due to the risk of aspiration. V2 stated R1 was peaceful and comfortable at this time. V2 stated that after R1 was settled, he went to the nursing station and continued with nursing duties. He did attempt to call R1's POA (V3) but it only rang once and the call was disconnected. V2 stated normally if she saw we called, she would call back or come in. V2 stated, It could be minutes, hours, or days before you would get a response. V2 stated at 9:30 AM, he checked on R1 again, removed the wash cloths, but did not check her temperature because it would not have given a correct reading. V2 stated R1 had no rapid breathing, nothing appeared abnormal, and R1 displayed no signs or symptoms of pain. V2 stated he did not attempt to wake R1 at that time opting to let her rest. V2 stated that he went back at 11:00 AM, rechecked her temperature and it was 101 degrees. He did try to wake her by speaking to her but she did not wake up. V2 stated he did another sternal rub and R1 did wake up, open her eyes, and groaned slightly. V2 stated R1's lungs were still clear at that time, she had no symptoms of respiratory distress, and her color was good. V2 stated he asked the CNAs if they would attempt to feed her at lunch and they reported back to him that R1 did not eat lunch. V2 stated the CNAs checked on R1 around noon, then V2 went back down around 2:30 PM when V3 showed up to visit R1. V2 stated he assessed R1 with V3 present, and her fever was 102 degrees. V2 stated he administered another Tylenol suppository and explained that R1 had cellulitis that could be causing the fever. V2 stated V3 tried to wake R1 up herself by repeating her name and when she did that, R1 started breathing heavier and more labored than what she had been previously. V2 stated he explained the options of keeping R1 in the facility would be to keep her comfortable, pain free, and without respiratory distress or they could send her to the ER and see if there was anything else that was going on they might be able to fix. V2 stated, V3 asked him what he thought, and he told V3 it was her decision, and that V2 could do either. V2 stated, I could start her on Morphine/Ativan or send her to the hospital. V3 then asked which hospital she should go to. V2 again told V3 that was her decision. V2 stated R1 did not appear critical at that time, so it was up to V3. V2 stated that V3 opted to send R1 to the hospital, claiming that the family would be mad at her if she didn't send R1 to the hospital. V2 stated V3 then said if they find anything serious, she was not going to do anything. V2 then told V3 he would call EMS and have her sent. V2 stated V3 asked him if she had to be there and he again told V3 that it was up to her but he would give report to the ER. V2 stated V3 left at that time, EMS arrived and did not do an in-room assessment - just got report from him. V2 stated, R1 was loaded on the stretcher and was in their hands after that. V2 stated he gave report to V12 in the ER. V12 called back about an hour later and explained to V2 that R1 had passed .that she coded when she came through the ER doors, (V12) attempted to intubate but saw what appeared to be aspiration of blood and assumed she had a massive GI bleed. They witnessed the POLST form DNR and did not proceed with intubation nor any further treatment. On 05/02/23 at 3:30 PM, V9 (Chief Executive Officer/CEO/Social Services) stated V3 came by the next day to get R1's belongings and praised the facility for the care of R1. V9 had with him the IDPH printout titled, Guidance Document for Illinois Health Care Professionals and Providers - Illinois Department of Public Health (IDPH) Uniform Practitioner Orders for Life-Sustaining Treatment and stated he wanted to go over the parts he highlighted. V9 then read from Page 2 of this document - healthcare professionals and institutional providers are legally protected from liability if, in good faith they honor the instructions contained in the POLST form . V9 stated, Which is exactly what we did. V9 stated R1's POLST indicated she was comfort focused treatment. V9 stated, This is the big one, and read the following from the document - Transfer to hospital only if comfort cannot be achieved in the comfort setting . V9 stated, We were going by what was on her POLST .I think we were within our guidelines and it's cut and dry we were following the resident's wishes. V9 read, POLST portable medical orders form, signed by the patient's qualified healthcare practitioner and either the patient or their legal representative, converts the patient's care choices into an actionable medical order that all other physicians, nurse practitioners, physicians assistants, long-term care facilities, hospices, home health agencies, emergency medical services, hospital staff, and other provider staff are required by law to honor . V9 also read, .the POLST model allows individuals to specify the intensity of medical interventions when they experience a life-threatening emergency where they still have a pulse. On 05/02/23 at 3:45 PM, V2 stated he believes the facility did everything as they should have and provided the care and comfort to R1 she required prior to her being transferred to the ER on [DATE]. When asked if V2 had anything else he would like to add to his interview, he stated, I stand beside the treatment R1 received in the facility on 04/11/23 and 04/12/23. If I had to do it over, I would do the same thing. I wouldn't change anything. The facility's 11/12/22 Notification of Changes in Condition policy documented in part . The facility must inform . the resident's family member or legal representative when there is a change requiring such notification. Circumstance requiring notification include: 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status . 3. Circumstances that require a need to alter treatment . According to https://www.polstil.org/resources-for-healthcare-providers/, the Guidance Document for Healthcare Professionals documents the following in part . POLST stands for 'Practitioner Orders for Life-Sustaining Treatment.' A POLST form is a signed medical order that travels with the patient to assure that a patient's treatment preferences are honored across settings of care. The POLST form is designed to ensure that seriously ill or frail patients can choose the treatments they want or do not want and that their wishes are documented and honored Use of the POLST form is voluntary. This form contains orders that can be revoked or changed at any time by patients or their legal representative When a patient's condition changes significantly, prior decisions about treatment should be revisited and consideration should be given to completing a new, updated POLST form. On 05/04/23 at 8:23 AM, V15 (LPN) stated prior to R1's fever the evening of 04/11/23, she did not appear to have anything going on. V15 stated, It seemed like it came out of nowhere. It seemed like it happened very quickly. V15 stated R1 would propel through the facility in her wheelchair but did stay in her room quite a bit. She was not able to ambulate or stand/transfer on her own but once she was in the wheelchair she could propel independently where she wanted to go. On 05/04/23 at 9:07 AM, V16 (CNA) and V8 (CNA) both stated normally R1 was awake and alert but sometimes she would get sleepy and tell us she just wanted to sleep. She had a habit of staying up at night sometimes and going through the drawers/packing her things to go home. V16 stated they would have to check the schedule but the last time they worked, R1 was fine. V8 stated the last time she worked and saw R1 was on 04/11/23 between 6:30 AM and 3:00 PM. V8 stated R1 had a shower that day and was tired after and wanted to sleep. V8 stated R1 slept in her recliner. V8 stated she did work the same shift on 04/12/23 but was not really involved with R1's care that day. However, there was nothing observed that would have given an indication R1 needed to be sent out to the hospital. She just knows she was sent out to the hospital and was surprised to hear she passed away. On 05/04/23 at 11:03 AM, V10 (RN) stated she did work on 04/11/23 from 2:30 PM to 7:00 PM. V10 was asked about R1's condition that day. V10 stated, I remember she started running a fever when I was getting ready to leave between 6:15 PM and 6:30 PM that evening. I gave her a Tylenol suppository and called (V2/APRN) to report the fever and lethargy and he said he would follow-up with (R1) the next morning. V10 stated R1 had episodes of lethargy in the past where she would look at you but would not speak. V10 reported they sent R1 to the hospital for a similar episode in the past and R1 told the hospital staff she just didn't want to talk to us and wanted to be left alone so she could sleep. V10 confirmed on 04/11/23, R1 did have redness to her legs, however, R1 had intermittent edema/cellulitis in her legs in the past that had been treated with steroid creams and wraps/socks. At times, it was cellulitis, but R1 did have chronic dermatitis. V10 stated, It was not too alarming at that point. I gave the night nurse the report and asked her to monitor R1. At that point, she just had a fever and was not verbalizing, so I thought it was like her past behavior. On 05/04/23 at 11:27 AM, V7 (LPN) stated it was normal for R1 to be incontinent. When asked about the events of her shift on 04/11/23, V7 stated, On 04/11/23, she did not want to get up and get in the shower, but she had been incontinent and had feces everywhere. She would not talk to us; she would glare at us and hold on for dear life to anything she could get a hold of. She would do the same thing to the CNAs in the past when they tried to get her up if she had been incontinent in her recliner through the night. V7 stated that R1 had been running a fever earlier in the day on 04/11/23 and received report it was coming down. V7 stated she kept checking R1's temperature and it was going down. V7 stated there was really no change in R1's condition from when she arrived to when her shift ended on 04/11/23, and there was nothing to make her think R1 should expire the next day. V7 stated that other than R1's leg being red, there was nothing different at all. R1 sat in her recliner with her head on her chest like she did every night. V2 was treating the redness to the leg with the Rocephin injection and antibiotic. V7 stated, I had been in contact with (V2) through the night regarding (R1's) condition and[TRUNCATED]