**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff, family, and provider interviews the facility failed to provide ongoing assessments, intervention, and physician updates to inform of an ongoing change in condition, for 1 of 6 residents reviewed (#1) who exhibited left leg swelling, intermittent pain, warmth, and a lump behind the left knee which resulted in the resident being transferred to a local emergency room with a blood clot on 6/6/23 after discharge from the facility to an Assisted Living home on 6/5/23. The facility reported a census of 89 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) dated [DATE] Resident #1 had admitted to the facility on [DATE] with diagnoses including malnutrition, muscle weakness, and COPD. The resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicating moderately impaired cognitive ability. The resident required extensive assistance of 1 staff for transfers, dressing, and personal hygiene. Review of Resident #1's Care Plan dated as created 6/1/23 identified the resident experienced the presence of frequent pain and directed staff to monitor for worsening pain symptoms and report to the physician. Review of electronic Progress Notes for Resident #1 included the following documentation related to left lower extremity: 5/26/23 at 11:20 a.m. Resident reported issues with the left side of her body being numb and a slight headache. Resident assessed, no facial drooping and hand grasps equal. Resident denies still having symptoms. 5/28/23 at 11:05 a.m. Resident complains of feeling weak while standing, family reported resident having calf pain, Homan sign (considered a sign of a deep vein thrombosis or blood clot of a deep vein) negative to Right leg. 5/29/23 at 10:37 a.m. Resident has 1+ edema to left lower extremity, no pain or warmth noted upon palpation. 5/30/23 at 8:42 a.m., Staff A, Licensed Practical Nurse (LPN) documented: Resident complains of pain to the back of her left knee. Area was warm and tender to touch. Question if palpated a very small lump to the posterior medial aspect of the knee. Call out to Provider AA. 5/30/23 at 11:10 a.m., Staff A, LPN documented: Area is no longer warm or tender to touch, denied pain currently. Family requested no intervention now, as resident currently being assessed by assisted living representative. 5/31/23 at 10:44 a.m. Staff B, Registered Nurse (RN) documented that family does not want resident to go out on appointment, call placed to Provider AA to see if she would come and see resident in the facility. 5/31/23 at 2:30 p.m. Staff B, RN documented Provider AA not able to come and see resident at facility, but is ok with resident seeing another group provider. 5/31/23 at 3:33 p.m. Edema to Left Lower Extremity is down. 6/3/23 at 8:47 a.m. Left leg is noted with 1+ edema, no erythema (redness) or increased warmth noted. 6/3/23 at 9:10 p.m. Staff C, RN documented called to room by patients two daughters. Concerned about swelling to the left leg. Assessment of left lower extremity, noted mild swelling. Denies pain upon palpation, no abnormalities felt, skin temperature normal. Resident given an ice pack to place behind knee and assisted to elevate. Temperature 100.8, Tylenol given and effective. 6/5/23 at 9:26 a.m. Discharge summary: resident left via private vehicle with family. Review of the electronic record temperature summary included the following: 6/3/23 at 7:25 p.m. 100.8 degrees Fahrenheit, forehead reading 6/4/23 at 3:54 p.m. 100.2 degrees Fahrenheit, forehead reading 6/4/23 at 7:06 p.m. 100.4 degrees Fahrenheit, forehead reading Review of a document titled Transitional Care Team Discharge Summary, completed by Provider BB, on 6/2/23 at 10:00 a.m. included: Resident has slight edema in her left leg, mild pain in her left calf. TED hose (compression stockings) have been ordered to be applied. Review of a Physician's Order Sheet and Progress Note dated 6/2/23 documented Provider BB ordered [NAME] hose on daily, OK to discharge to assisted living facility. Provider BB documented left leg +1 edema, pain in the left calf, no redness or warmth. Review of a Health Care Provider's Order sheet, dated as written on 6/2/23 at 10:23 a.m. by Provider AA revealed a new order for compression stockings (medium) knee high, and Lasix (diuretic) 20 mg daily as needed for edema. Review of Occupational Therapy Treatment Encounter Notes included the following: 5/30/23 Patient reporting discomfort in the neck, back, and left lower extremity. Pain with movement rated 8/10. Patient limited by pain to session interventions. 5/31/23 Nurse came in to check on resident left lower extremity due to pain. Resident not agreeable to completing STS (sit to stand) transfer to a 2 wheeled walker. Pain with movement rated 5/10. 6/1/23 Session missed as resident being assessed. 6/2/23 Resident agreeable to theraband exercises for bilateral upper extremity strength, rated pain at rest 3/10, location left lower extremity. Review of Provider AA's clinic encounter notes included: Clinic RN attempted to return a call to the facility on 5/30/23 at 9:18 a.m. Noted on hold too long. 5/31/23 at 10:55 a.m. Clinic RN documented Staff B, RN had reported that resident on skilled level of care and a provider has to stop in and see her at the facility. Wants to know if Provider AA will see her or if another provider is available to see her. 5/31/22 at 2:24 p.m. Provider AA instructed to call facility and let know that Resident will either need to come in for an appointment or see another provider prior to her discharge. 5/31/23 at 2:28 p.m. clinic medical assistant noted had spoken to Staff B, RN and she will have Provider BB take care of it. 6/1/23 at 3:10 p.m. clinic medical assistant noted family had questioned if anyone had contacted Provider AA regarding lower extremity edema and possible an order for compression stockings. 6/2/23 at 7:57 a.m. Provider AA requested clinic staff call facility with a verbal order for compression stockings plus Lasix 20 mg as needed for edema. 6/2/23 at 9:39 a.m. clinic medical assistant spoke to facility staff nurse who reported Resident #1's left ankle does have some edema, denied pitting edema. Stated that resident would benefit from compression stockings. Review of a facility form titled Concern Investigation form, dated 6/6/23, provided by the Director of Nursing (DON) documented that a family member informed the facility that Resident #1 had been taken to the emergency room and has a blood clot behind her left leg. Additionally, documented family had told multiple nurses about the pain in the left leg During an interview on 11/8/23 at 2:15 p.m. Staff A, LPN recalled on 5/30/23 at 8:44 a.m. Resident #1 had complained of pain to the back of the left knee. Noted the area was warm and tender to touch, confirmed she had found a small lump behind the knee, and the left lower leg was swollen. Responded that she had been concerned about a blood clot, so had called Provider AA, but had not received a return call. When asked what she would expect to have done in response to a suspected blood clot, she responded that she should have made a mark and measured the circumference of the leg at the mark so they could monitor, however stated she had not measured. Further responded that she should have checked for a positive Homan's sign, which she thought she may have done, but should have documented and had not. Additionally stated, would be expected to assess skin temperature, look for redness, swelling, pain, notify provider, and put on report for the next shift. Staff A had further documented prior to the end of her shift that area was no longer warm or tender to touch. Stated when you call a provider and don't hear back would assure communicated to the next shift, and would expect them to follow up. Staff A stated she couldn't recall if she had passed on the information through daily shift report. On 11/9/23 at 3:37 p.m. Staff A, LPN clarified that she had shared her assessment when she notified the provider's office on 5/30/23. The facility was unable to provide daily report sheets for 5/26/23-6/5/23. During an interview on 11/8/23 at 2:52 p.m., Staff B, RN/Assistant Director of Nursing (ADON) recalled that she had been alerted on 5/31/23 that Provider AA was unable to see Resident #1 at the facility to complete a discharge assessment and documented would attempt to get a provider to see in house as family didn't want resident going out for an appointment. The ADON confirmed that Provider BB had seen resident on 6/2/23. Reviewed with the ADON that Staff A reported had been concerned about a blood clot on 5/30/23 and had made a call to the provider, but hadn't received a return call. The ADON responded that if suspected a blood clot and hadn't heard back from the provider would send to the emergency room. Would additionally expect to be on report for ongoing monitoring through assessment which would include measuring the circumference of the leg, Homan's sign, pain, and redness which she would expect to be documented. The ADON confirmed she had not been aware that Staff A had been concerned about a blood clot when had placed a call to the provider. Stated had she been aware she would have assessed the leg. In an interview on 11/8/23 2:42 p.m. Staff C, RN confirmed had documented on 6/3/23 at 9:10 p.m. that resident had swelling of the left leg, ice pack for behind knee and elevate. Staff C responded that she usually reviews documentation for previous concerns but could not recall that she had looked back or had been made aware of concerns regarding pain or swelling of left leg or the possibility of blood clot. Staff C recalled that the pain in the left leg had been all over, not specific. Stated that there had been mild swelling, but not pitting edema, denied that she had measured the leg. Stated that when you suspect a blood clot you would expect to assess for tenderness, pain in the calf, Homan's, redness, measure circumference, continue to monitor, contact the provider, and document. Stated that with a suspected blood clot wouldn't expect to apply an ice pack. In an interview 11/9/23 at 9:20 a.m. Provider BB stated she was asked to do a discharge assessment and summary on Resident #1 prior to her discharging to an Assisted Living facility. Provider BB stated that she does not recall being informed of any concerns with left leg pain or swelling prior to completing the assessment. Confirmed she had documented plus 1 edema and calf pain in the left leg. Responded that it would have been helpful to have that information when completing her assessment and might have changed her direction to the staff. Might have ordered a doppler rather than compression stockings. Stated the nurse usually gives her a brief summary before she sees the resident, does not recall the day of the assessment. Additionally, stated was not aware of pain in left leg when standing, as documented by therapy when completing a one person assist. Stated she was seeing resident in lieu of Provider AA who does not come to the facility, and family had not wanted the resident to have to leave the facility. During an interview on 11/9/23 at 2:15 p.m. Provider AA stated on 5/31 the ADON had called the office nurse multiple times attempting to schedule a last visit before discharge for Resident #1, with the final result that Provider BB was scheduled to see. Provider AA denied there was any record of a call from the facility informing of left lower leg pain, swelling, warmth, or a lump. Provider AA reviewed notes that resident discharged to an Assisted Living facility on 6/5/23 and on 6/6/23 was taken to the emergency room by family due to swelling, pain, and warmth over the last 5 days. Provider AA stated she absolutely, 100 percent would have expected to be informed of the left side lower extremity swelling and pain and would have sent them out to the emergency room. Provider AA reported resident diagnosed with a Deep Vein Thrombosis (DVT), blood clot, of the femoral and of the popliteal vein on 6/6/23 in the emergency room, after she had been discharged to assisted living on 6/5/23. Provider AA reiterated that she would have expected to have been informed by the facility and stated that her opinion is the symptoms that Resident #1 had experienced at the facility were related to the DVT found at the emergency room. In an interview on 11/9/23 at 2:48 p.m. the admission Nurse from the Assisted Living facility stated she had completed the admission assessment virtually, and had not been provided any information that the resident had left leg pain until she arrived at the assisted living. Therapy assessed upon admission, was informed of leg pain and swelling and when continued the next day was informed by family that resident had been experiencing for 7 days, was sent to the emergency room. In an interview on 11/14/23 at 10:39 a.m. family reported they had been very concerned about the swelling, pain, and a lump in resident's left lower leg from 5/27/23-discharge. They had reported to multiple nurse's and felt they had not taken it seriously. When transferred to assisted living, Resident #1 was assessed and there was concern about the pain, and swelling of the left leg. On 6/6/23 the pain and swelling continued and the resident was taken to the emergency room where they found a blood clot. Review of a policy titled: Change of Condition/Hot Chart Protocol, Nursing Guidelines and Procedure Manual, January 2015 edition, provided by the DON as a facility policy, revealed the licensed nurse is responsible to provide care to residents through nursing assessments, interventions, and appropriate follow up. A definition of condition change included: an alteration from normal status. Could include, but not limited to: skin changes, vital sign changes, physical decline in residents' condition. Guidelines included: observe/assess resident to determine status, notify attending physician as appropriate, carry out new orders, monitor resident for response. Documentation directives included: date and time of assessment and any interventions provided, date and time physician notified and if orders are received, observation and assessment of resident, to include response to intervention until the problem resolves.