**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and provider interviews, and policy review the facility failed to contact the provider, and provide intervention for health condition changes noted with a pre-dialysis assessment prior to transfer to a scheduled dialysis appointment on [DATE] for 1 of 3 residents reviewed (Resident #1) who was assessed as lethargic, pulse of 47, and pulse oximeter (oxygen level) 87% on room air. Resident had been diagnosed with Covid-19 on [DATE] and had been experiencing loose stools, lack of appetite, weakness, and confusion. Resident arrived at the Dialysis Center, 30 miles from the facility, non-responsive, with diminished lung sounds, Blood Pressure (BP) 66/32 and required immediate transfer to the local emergency room (ER) for stabilization of life-threatening conditions. These circumstances posed Immediate Jeopardy to resident health and safety that began on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE] at 1:25 p.m. The facility took appropriate steps to remove the immediacy on [DATE] at 4:35 p.m. by taking the following actions: *Ensuring ALL nurses working for the facility were educated on the Family and Physician Notification policy. *Providing a table with parameters with over 100 situations for staff to use as guidelines for when Physicians need to be notified of resident condition changes to use along with nursing judgement and the Electronic Health Record computer system parameters. *Ensuring ALL nurses signed acknowledgement of receiving and understanding the training provided. The facility reported a census of 57 residents. Findings include: According to a discharge assessment-return anticipated Minimum Data Set (MDS) dated [DATE] Resident #1 admitted to the facility on [DATE] and discharged to a short-term acute hospital on [DATE]. The MDS documented diagnoses that included Diabetes Mellitus, end stage renal disease, non-displaced intertrochanter femur fracture (hip fracture), and an unstageable pressure ulcer. The resident had moderately impaired decision making and evidence of an acute change in mental status from the resident's baseline which included a continuously present altered level of consciousness. The resident's usual performance at the end of the stay was coded as dependent, helper does all the effort, for toileting, shower, and transfer and required substantial assistance to roll form right to left and return to lying on back in bed. Review of Resident #1's baseline Care Plan initiated on [DATE] identified the resident admitted to facility for care related to end stage renal failure and after care following a right femur fracture. Cognitive status described as alert and oriented to person, place, time, and situation. Dialysis on Monday/Wednesday/Friday leave facility at 5:45 a.m. transportation by a local transport service to and from the facility. A focus area identified laboratory confirmed Covid-19 with a goal to avoid hospitalization with a target date of [DATE]. Interventions included: monitor vital signs including SPO2 (oxygen levels) every shift, keep head of bed elevated, encourage fluids and good nutritional intake. Review of a facility document titled Advance Directive Acknowledgement dated as signed by Resident #1 on [DATE] specified that resident requested resuscitation. Review of an electronic Physician Order form for Resident #1 revealed an order dated [DATE] for Cardiopulmonary Resuscitation (CPR), full code. Review of electronically recorded Vital Signs (VS) included the following: [DATE] 5:35 a.m. pulse 47 beats per minute (bpm) [DATE] 2:35 p.m. pulse 113 bpm, O2 (oxygen) 87% room air [DATE] 2:10 p.m. pulse 98 bpm, 92% room air [DATE] 10:44 a.m. pulse 76 bpm, 95% room air [DATE] 7:05 a.m. pulse 78 bpm, 98 % room air [DATE] 5:27 p.m. pulse 80 bpm, 99% room air Review of electronic Progress Notes for Resident #1 included the following documentation: [DATE] at 4:13 p.m. Dialysis center contacted about resident's positive Covid-19 test today, they will complete dialysis as usual. [DATE] at 4:30 p.m. Staff A, Licensed Practical Nurse (LPN) secured communication with Physician included: notification Covid-19 positive. 5:05 p.m. Response: resident not a candidate for Covid-19 treatment, directed to treat signs and symptoms or send to emergency room (ER) if worsens. 5:12 p.m. Response addendum-send resident to ER if difficulty breathing, confusion, etc. [DATE] at 1:21 p.m. Oriented to person, place, and time. [DATE] at 1:44 p.m., the Director of Nursing (DON) communicated through a secured message with the Advanced Registered Nurse Practitioner (ARNP) resident not dizzy, but is pale, somewhat confused and voice very soft. Barely eating and drinking. Resident Covid-19 positive. May have you see on Thursday ([DATE]). Resident is also a full code. [DATE] at 5:30 a.m. Staff B, LPN noted resident with very loose watery stools. Coccyx area dark purple in color. [DATE] at 5:37 a.m. Staff B, LPN completed a dialysis assessment. Temperature 98.7, pulse 47 and irregular, Respirations 16, and O2 level 87 % on room air. Level of consciousness: lethargic. [DATE] at 7:56 a.m. Staff A, LPN noted dialysis center called to inform resident had not had dialysis. Resident was unable to follow commands, unresponsive, cool to touch. Sent to ER by ambulance. Review of a fax communication from the dialysis center revealed a note created by the Dialysis Nurse on [DATE] at 7:51 a.m. The note included the following: Resident #1 arrived at the facility for treatment. Resident very pale and moaning, right eye is closed and left eye is open but staring off, does not blink when wave hand in front of face. Resident nonresponsive to commands, blood sugar 127, BP 66/32, respirations shallow, lungs clear but diminished. Left hand is cool to touch. Noted to have reaction only to painful stimuli, such as moving via mechanical lift to transport to ER. Dialysis Provider was notified and ordered for resident to be sent to local ER for evaluation. Resident was transported by ambulance to the local ER. Staff A, LPN was notified of the transfer and reported that resident had tested positive for Covid-19, knew the resident was not doing well and expected this. Review of an Emergency Department (ED) note dated [DATE] at 7:27 a.m. revealed resident arrived to dialysis unresponsive. Resident not answering questions appropriately upon arrival to ED. Does moan in pain. Resident assessed to have Atrial Fibrillation, colovaginal fistula (an opening between the vagina and the colon), and bilateral pneumonia. The summary noted that given the high probability of imminent or life-threatening deterioration of the resident's condition without intervention, the resident was immediately assessed, monitored and treated. Resident was admitted to the hospital for ongoing care. In an interview on [DATE] at 11:29 a.m. the Dialysis Nurse stated that Resident #1 had arrived for dialysis at approximately 6:15 a.m., and she was immediately concerned. Stated the resident appeared very pale, unresponsive to commands, responsive only to painful stimuli, unable to obtain a blood pressure with the automatic machine, able to get a blood pressure of 66/32 with a manual cuff. Stated she had notified the Dialysis Provider who ordered Resident #1 to be sent to ER by ambulance, no dialysis. Further stated she had contacted the facility and informed Staff A, LPN of condition and reported emergency transfer. Staff A commented that she knew resident wasn't doing good and expected her to need to go to the ER. The Dialysis Nurse stated Staff A's response had surprised her, wondered why the facility hadn't called the provider or the dialysis center to notify of condition change rather than transporting to dialysis in poor condition. In an interview on [DATE] at 1:05 p.m. the Administrator stated on [DATE] she had come in at 2:00 a.m. to work as a Certified Nursing Assistant (CNA) and had assisted Staff B, LPN to get Resident #1 ready for dialysis in the morning. She recalled that the resident had very loose stools, wasn't eating, weak, sleepy, much like the other resident's with Covid-19. Stated as she finished cares she heard the entrance door sound indicating that transport had arrived and was not in the room when Staff B completed her assessment. The Administrator estimated that transport arrived at 5:45 a.m. She described that the transportation service was a single driver and the resident was transported in her wheelchair in a van. In an interview on [DATE] at 1:35 p.m. Staff B, LPN stated that she had assisted the Administrator complete cares and get Resident #1 ready for dialysis in the early morning on [DATE]. Further informed she had completed the pre-dialysis assessment and had concerns about the resident's health status. Additionally, had noted at this time that resident's coccyx was deep purple in color, which had not been there the day before. Stated she was glad that Resident #1 was going to dialysis where they knew her better than they knew her at the facility. Added that the doctors at dialysis knew her better because the facility hadn't really gotten to know her baseline as she had been diagnosed with Covid-19 the day after she had arrived. Stated resident had informed them she gets sick really fast when her dialysis schedule is altered, as it was for the Christmas holiday. Responded that transportation was just a single driver, and no further assessment would be provided during transfer. Recalled that when she took vitals her hands were so cold, always cold, so assumed that was why the oxygen level was so low. During an interview on [DATE]/at 10:46 a.m. Staff A, LPN stated she had notified the provider of Covid-19 positive test on [DATE], he had responded unable to treat with medication for Covid-19 and instructed with a change of condition to send to the ER. Staff A, LPN worked the day shift on [DATE] and had received report from Staff B, LPN who had completed the pre-dialysis assessment. Staff A stated that she would have called the provider right away for a pulse of 47, oxygen level of 87% on room air, and resident lethargic, to report condition change. Responded that the direction she had received from the provider when resident initially diagnosed with Covid-19 was to notify the provider of condition change and send to ER for further evaluation. Further interview on [DATE] at 11:51 a.m. Staff A responded that she had not been surprised when the Dialysis Nurse had informed her the resident had not had dialysis and required emergency transfer to the ER for evaluation and treatment because Staff B had informed her of her assessment at report. Again, stated that she would have called the provider to report the change in condition prior to sending to dialysis. In an interview on [DATE] at 3:40 p.m. the DON stated that she would have expected Staff B, LPN to notify the provider of a change in condition after pre-dialysis assessment prior to sending the resident with transportation with a pulse rate of 47, Oxygen level of 87% on room air, confusion and weakness. Responded that the transportation provided was just transportation without medical assistance or assessment provided during transport. Stated typically takes 30 minutes to transport to the dialysis center from the facility. Responded that Resident #1 was a full code, requested CPR. She added, the facility had identified a concern and discussed what could have been done differently that day. In an interview on [DATE] at 3:40 p.m. the Assistant Director of Nursing (ADON) stated that she would have expected the provider to be notified on [DATE] of the condition change noted during the pre-dialysis assessment prior to transferring to dialysis. In a phone interview on [DATE] at 10:58 a.m. the Primary Provider's Nurse stated she had talked to the provider, he had reviewed and would expect to have been notified of the condition change, specifically the low oxygen level, confusion, lethargy and would have instructed the facility to send Resident #1 to the ER. Stated resident had been a patient of the provider while living at home prior to admission to facility and was very familiar with her. Review of an undated facility policy titled, Family and Physician Notification relating to an accident or change in medical condition included the following: The facility will immediately notify the resident, the resident's responsible party and the physician of a change in the resident's medical condition which includes a deterioration in health. The charge nurse working at the time will notify the physician, notification will also include the results of a full body assessment and vital signs. Documentation will be recorded in the resident's medical record. Vital signs that are to be reported immediately to the physician included a resting pulse of less than 55 bpm. Review of Resident #1's profile page in the electronic record revealed that the following vital signs were alerted in red, and displayed a yellow triangle which contained an exclamation point to the left of the vital sign: Pulse: 47 bpm [DATE] at 5:35 a.m. O2: 87% [DATE] at 2:35 p.m. In an interview on [DATE] at 9:35 a.m. the DON responded that vital signs that are out of parameter will alert red in the clinical record as had Resident #1's pulse and oxygen level. The DON reviewed the facility policy and stated that the policy failed to identify a parameter for notification for oxygen level. Continued interview with the DON and the Corporate Nurse Consultant, at 9:40 a.m. the Corporate Nurse Consultant stated the standard alert for oxygen levels is 90%, anything less than 90% would trigger red in the electronic record and require reassessment, follow up, and provider notification.