**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility records, hospital records, staff, family, and physician interviews, and facility policy review the facility failed to have a nurse assess 1 of 3 residents (Resident #1) after two Certified Nursing Assistants (CNA) reported the resident had experienced a change in condition. On [DATE] two CNAs reported to the nurse at about 6:30PM-7:00 PM they noted her oxygen saturation was 63% on room air, blood pressure (BP) was 79/39, they rechecked it and it was 88/68. When the nurse on duty was notified she told the CNAs to put oxygen on her via oxygen concentrator at 2 liters (L). The CNAs rechecked Resident #1's oxygen saturation 20 minutes later and it was 92% but the resident seemed confused, not very aware and appeared to be in pain. The CNAs reported their concerns to the nurse again but she did not seem worried or concerned. The CNAs checked on Resident #1 around 8:00 PM-8:30 PM and her oxygen saturation went back down to 72%. The nurse told them to turn her oxygen up to 3L. They did that and reported the resident's vitals never got better than that for the rest of their shift. When the overnight nurse came on shift at 10:00 PM, the CNAs reported their concerns about Resident #1 and that she needed to go to the hospital. The oncoming nurse agreed and the resident was sent to the emergency room (ER) at approximately 10:30 PM, 4 hours after staff first reported her change in condition. The resident passed away on [DATE] at the hospital with a cause of death documented as congestive heart failure. This resulted in an Immediate Jeopardy (IJ) to residents' health and safety. The State Agency informed the facility of the IJ that began as of [DATE] on [DATE] at 12:09 PM. The immediacy was removed on [DATE] at 5:03 PM when the facility submitted an acceptable removal plan. The facility's removal plan documented the following actions: 1. Resident was discharged on [DATE]. 2. Will educate nurses in regards to assessments and interventions. 3. Will educated CNAs to report to another nurse in the facility or notify on call nurse if they feel the resident's change in condition is not appropriately addressed. 4. Facility will review progress notes in order to identify change in condition and implemented interventions were appropriate. 5. Director of Nursing (DON)/Designee will review any change in condition 3 days per week for one month then weekly for one month. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 39 residents. Findings include: The annual Minimum Data Set (MDS) with a reference date of [DATE] documented Resident #1 required extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, dressing, and personal hygiene. She also required limited assistance of one staff for walking in her room and in the facility while using a walker or wheelchair. The quarterly MDS with a reference date of [DATE] documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 out of 15 suggested no cognitive impairment. The following diagnoses were documented for Resident #1: hypertensive heart failure, coronary artery disease, anxiety, depression, history of falling, urine retention, and thrombocytopenia. The Care Plan focus area with an initiation date of [DATE] documented Resident #1 was on an anti-coagulant therapy to manage her diagnosis of atrial fibrillation. Staff were encouraged to observe, document, report as needed (PRN) any adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. The Progress Notes documented the following for Resident #1: -On [DATE] at 10:12 PM follow-up from a fall today. This nurse checked on her after receiving report at 10:00 PM. Resident #1 would moan when she was asked questions, would not open her eyes. This nurse noticed increased edema in her feet and hands. Vital signs as follows: temperature 97.7 F, pulse 50-53 beats per minute (BMP), respirations 20, blood pressure (BP) 90/40 and oxygen saturation 94% on 3L of oxygen. Oxygen saturation would go back down in low 70's when they would take off the oxygen. The nurse on call was notified at 10:15 PM and the resident was sent to the ER to be evaluated and treated. Resident #1 left the facility by ambulance at 10:30 PM. Her family was notified and would like updates when received. This progress note was documented by Staff A Licensed Practical Nurse (LPN). -On [DATE] at 4:11 AM this nurse called to get an update on Resident #1. The hospital staff stated her head scans were clear, was admitted for respiratory acidosis and is currently on BiPAP (machine to provide different air pressure levels for inhalation and exhalation). Review of Resident #1's [DATE] Treatment Administration Record (TAR) revealed she had an as needed (PRN) oxygen order at 2 liters via nasal cannula for signs and symptoms of hypoxia with a start date of [DATE]. The Clinical Report from the ER on [DATE] documented the following: -On [DATE] at 10:34 PM Resident #1 arrived to the ER by ambulance. She fell earlier today, on warfarin (blood thinner) and start noted she was having altered mental status, hypoxia (low oxygen), low blood pressure. Resident obtunded (diminished responsiveness to stimuli) since this afternoon. She required oxygen, normally does not require it and not responsive to questions. Her son reported he saw her around 1:00 PM and was able to verbalize about the fall and what happened. Tonight, she is unable to verbalize what happened. -Physical exam: she is obtunded, appears uncomfortable, pale, dehydrated and appears elderly. Respiratory distress, decreased breath sounds, wheezing is present. -Clinical impression: acute mental status change with lethargy, respiratory acidosis, hypercapnia (carbon dioxide build up in bloodstream), hypoxia, and fall. -Resident was admitted to the medical/surgical unit. The History and Physical with a date of service of [DATE] documented the following: -Past medical history of chronic heart failure, atrial fibrillation, anticoagulated use, presenting with altered mental status and hypoxia from the nursing home after a fall. The nursing home stated that she fell today and did not do neurological checks on the resident. The night nurse noticed that she was not acting right. The family would like a do not resuscitate (DNR) do not intubate (DNI) status, no transferring, would like fluids but no lines or tubes. Resident does not use oxygen a home. -Physical exam: mild wheezing on the left side, +4 pitting edema to extremities -Assessment/Plan: acute hypoxic respiratory failure. Resident has been on 10L high flow oxygen with current oxygen saturation of 99%, on diuretics and does have +4 pitting edema so this likely chronic heart failure exacerbation. Review of the Certificate of Death with a date filed of [DATE] documented Resident #1 expired on [DATE] at 8:12 PM with an immediate cause of death documented as congestive heart failure. Review of the nurse communication reports revealed no report found for [DATE] from Staff B Licensed Practical Nurse (LPN). Staff A LPN documented on [DATE] at 2:15 AM Resident #1 sent to the ER at 10:30 PM due to low blood pressure, pulse, oxygen saturation, and unresponsive. Resident did have a fall earlier in the day. The resident admitted for respiratory acidosis and x-ray pending to check for chronic heart failure. On [DATE] at 8:24 PM Staff A documented resident passed away. Review of clinical and facility records revealed the facility could not locate the CNA assignment sheet and vitals sheets for [DATE]. On [DATE] at 11:29 AM Staff D CNA stated she worked the evening shift on [DATE] with Resident #1. She stated they were doing vital signs on her every 2 hours because of a fall that occurred earlier in the shift. At about 6:30 PM-7:00 PM she noted her oxygen saturation was 63%, blood pressure was 79/39 and when she checked it again it was 88/68. She stated when she told Staff B Licensed Practical Nurse (LPN) about the resident's vitals, the nurse told her to put oxygen on at 2L. Roughly 20-30 minutes later Staff D rechecked the resident's oxygen saturation and it went up to 92%. Staff D stated while attempting to talk to the resident to see how she was doing, she was confused, not aware and complained of being in pain. She stated she used the Hoyer lift with Staff C to get her to bed. Staff D again told Staff B her concerns but she did not seem worried or concerned, and just said ok. Staff D stated her and the other aide continued to check on her more frequently, and that was their own choice to do that. At about 8:00 PM-8:30 PM the residents oxygen saturation was at 72% and when they told Staff B, she told them to turn her oxygen up to 3L. The residents vital signs did not get better nor did they get worse. When the overnight nurse came in, Staff D pulled her aside, told her what was going on and that she needed to go to the hospital. Staff A told her she would send her out right away. Staff A sent the resident to the hospital 4 hours after they let Staff B know of her decline. On [DATE] at 12:17 PM Resident #1's emergency contact #1 stated when he visited with his mom that afternoon she was fine. She was sitting in her chair and talked about her fall. The staff came to get her for lunch and he said his goodbyes. He added that was the last time he talked to her. On [DATE] at 2:46 PM Staff B denied being told any concerns about Resident #1 from the CNAs that evening. When asked if anyone reported Resident #1's BP being low on [DATE], she said no. When asked if anyone reported her oxygen saturations being low she said no, then said maybe they did. She stated staff had put the resident in bed that night and her saturation was low so she told them to put her as needed (PRN) order of oxygen on. Staff B indicated about 20 minutes after she advised staff to put her oxygen on she went to check on the resident and her levels were about 94%. Staff B stated the resident passed away at the hospital that night and she was not sure why. At 10:00 PM she told the oncoming nurse, Staff A, she should send the resident to the hospital but was sent out about 1:00 AM because she was unconscious. On [DATE] at 4:01 PM Staff C CNA stated she came in to work at 6:00 PM on [DATE] and when she went in to Resident #1's room she was not her normal self. Staff C stated Resident #1 usually would call Staff C by her name, talk about her kids but she could not tell her own name or Staff C's name and it was just not normal conversation. At about 6:30 PM-6:45 PM Staff C stated the resident's oxygen saturation was alarming, not sure on the number but remembered it was less than 90% as she sat in her wheelchair. Resident #1 did not have oxygen on at that time but when they told Staff B about her oxygen saturation she told her to put it on, so they did. Staff C stated roughly 45 minutes later she went back in to Resident #1's room and her oxygen saturation was a bit better, not good and was still alarming. The resident continued to not be herself. She wanted to lay in bed when normally she would want to talk about her day, ask to change the television and eat a snack. She stated she used the Hoyer lift with Staff D to put the resident in bed so it would be easier to check on her. She was very tired and out of it. About an hour after they put her oxygen supplement on they checked her again; she was not responding, they would say her name, she would say huh and not answer. They continued to check on her until the overnight nurse came on at 10:00 PM and sent the resident to the ER. When they told Staff B about their concerns, she indicated she assessed her and she was fine. Her and the other CNA were assisting other residents so she was unsure if Staff B actually went in to assess Resident #1. Staff B reported she was fine and awake but when her and Staff D went back in the resident's room she was still not responding. She felt Staff B could have done more. Staff C stated she documented her vitals on her CNA assignment sheet that they give to the DON to have on file. On [DATE] at 7:02 PM Staff A stated she worked on [DATE] from 6:00 PM until 6:00 AM on [DATE]. She stated she was working in the building the day Resident #1 had a decline. She was working on the other side of the building from 6:00 PM-10:00 PM and at 10:00 PM she went to get report from Staff B so she could go home. Staff B stated the resident had fallen earlier in the day was lying in bed and was out of it. Staff B stated earlier in the shift her blood pressure and pulse bottomed out and her oxygen was really low. Staff B reported the resident was now on oxygen because her oxygen saturation dropped to 60% after supper and was doing fine. After Staff A completed report she went straight to Resident #1's room to do an assessment. The resident would not open her eyes or wake up, just moaned, her oxygen saturation was 93-94% and her blood pressure was 90/40. The evening shift CNAs also reported to her the resident's blood pressure and oxygen was low. As soon as she heard that information in report she knew the resident was not ok and that is why she went down to her room right away. Resident #1 was sent to the ER on 10:30 PM. Staff A stated based on what information was given to her during report and what the CNAs reported to her, the resident should have been sent out sooner. On [DATE] at 10:30 AM the Director of Nursing (DON) stated Staff A called her on the night of [DATE] and informed her she was sending the resident to the ER. When asked what was going on Staff A told her the resident had edema in her feet, her oxygen saturations were low and she wanted to send her for evaluation. The next day the DON called to get an update and the hospital informed her the resident was on BiPAP, and waiting for family to arrive. She learned later that Resident #1 had passed away. When asked if she spoke to the CNAs that worked the evening she stated she only spoke to Staff A. The DON was informed of what the CNAs had observed from 6:00 PM until 10:00 PM on [DATE] and she denied being aware of the events that took place. She indicated it was normal for Resident #1 to have edema to her feet. The DON was informed the CNAs felt Staff B did not do enough for the resident, she stated if the resident had a decline a total assessment should have been completed. The DON stated the physician should have been notified and they would go from there but she was not aware the resident had experienced a change in condition at that time. The DON felt their facility had open lines of communication and has had staff members text her with issues. The DON stated Staff B never said anything to her and she was unsure how to dispute the concerns if she did not know what was going on. She denied receiving information about Resident #1's low oxygen, low pulse and low blood pressure. She acknowledged there would have been another nurse in the building at that time that the CNAs could have reported their concerns to. The DON was notified of the missing CNA assignment and vital sheet from [DATE]. She was unsure why that particular sheet was missing. On [DATE] at 1:47 PM when asked the Medical Director if a resident experienced confusion and disorientation if that would require a call to the physician, he stated that would be a significant change in condition that would require a call to the physician. The facility's Change in a Resident's Condition or Status Policy with revised date of February 2021 documented the following policy statement: out facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician on call when there has been a(an): a. Accident or incident involving the resident d. Significant change in the resident's physical/emotional/mental condition Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Except in medical emergencies, notifications will be made with in twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.