**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and physician interviews, the facility failed to obtain and clarify physician orders that directed a resident's care, failed to follow physician orders, and failed to complete accurate assessments that included regular circulation and skin assessments of a resident with a casted arm, that resulted in a wound infection, wound dehiscence (separation of a closed surgical incision) with exposed hardware and bone, that required immediate hospitalization and surgery when identified 15 days after admission to the facility, for 1 of 8 records reviewed (Resident #1). The failure resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility also failed to implement appropriate interventions in a timely manner for Resident #1, and Resident #6, when significant changes of condition that included pain level rated at 10 out of 10 on a 0 to 10 pain scale, with 10 assigned to the highest level of pain, and circulation changes that included the development of worsened pitting edema that weeped fluid, did not implement appropriate interventions, and did not notify the physician of Resident #1's and Resident #6's condition changes or seek direction to provide care consistent with the condition changes and resident needs. The facility reported a census of 74 residents. Findings include: 1. The [DATE] admission Minimum Data Set (MDS) assessment recorded that Resident #1 admitted to the facility [DATE], had diagnoses that included Non-Alzheimer's dementia, schizophrenia, fractured hip and other fracture. The assessment documented she had severely impaired cognitive skills for daily decision-making, symptoms of delirium, she did not speak and rarely or never could make herself understood or understand others. Resident #1 required extensive assistance of at least 2 staff for transfers to and from bed and chair, dressing, eating, toilet use, bathing and personal hygiene. She was always incontinent of bowel and frequently incontinent of urine. Review of a hospital History and Physical form revealed that Resident #1 had an operation for open reduction and internal fixation (ORIF) of the right hip and olecranon (elbow area of the humerus, upper arm bone) completed on [DATE] by an orthopedic surgeon. Hospital Discharge Orders dated [DATE] directed the resident's admission to the facility at a skilled level of care, with physician orders that included: a. Schedule follow-up appointment with Orthopedic Surgeon within 2 weeks. b. Administer 2 Acetaminophen (Tylenol) 325 milligrams (mg) tablets (650 mg dose) orally 4 times daily. c. Resident #1 to wear sling to right arm. The Discharge Orders stated incisions were present on the right hip and right elbow, but did not direct what incision or wound care was required. A Cast or Splint Care, Adult Instruction Form, revised [DATE] and included with the resident's Hospital Discharge Orders, directed staff to contact the health care provider if the skin around the cast or splint got red or raw and/or the skin under the cast was extremely itchy or painful. The resident's 9/22, 10/22 and 11/22 Medication Administration Records (MARs) recorded that Resident #1 received 1 tablet of Acetaminophen, 325 mg orally 4 times daily from the time of admission on [DATE] until the time of her discharge on [DATE] and from the resident's return on [DATE] through [DATE] when reviewed. An Impaired Skin problem on the resident's Nursing Care Plan, initiated [DATE], documented the goal that Resident #1 would not have complications related to skin impairment, directed staff: a. Educate me, my family, and caregivers of causative factors and measures to prevent skin injury. b. Monitor for and document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection to physician. c. Weekly treatment documentation to include, measurement of each area of skin breakdown, type of tissue and exudates, and any other notable changes or observations. The resident's record did not contain physician orders that directed the resident's wound care, or care of the cast, and no interventions on the Nursing Care Plan specific to assessment of the resident's circulation, motion and sensation (CMS) of the casted extremity as required by professional standards of practice, between [DATE] and [DATE]. The resident's record lacked documentation of CMS (circulation, motor and sensory) assessments of the right arm at least every nursing shift, as directed by professional standards of practice. A Nursing Progress Note dated [DATE] at 11:25 a.m. and authored by Staff A, Licensed Practical Nurse (LPN) documented Resident #1 showed non verbal signs/symptoms of pain with movement, however, denied pain when asked. A Nurses Note on [DATE] at 10:42 a.m. by Staff A recorded that Resident #1 had post right hip and right elbow fractures with surgical intervention. The bandages to both were clean, dry and intact, and not to be removed until follow up appointments. Resident #1 continued to deny pain; however does show non verbal signs and symptoms of pain during transfers. A Nurses Note dated [DATE] at 3:05 p.m. recorded Staff B, Registered Nurse (RN) noted an abrasion to Resident #1's right inner wrist. The abrasion had an intact scab, and no odor, drainage or redness. Staff B cleansed the area and left it open to air at this time. The nurse notified the local general practice physician of the area. A fax (facsimile) to the same physician transcribed by Staff B on [DATE] at 3:06 p.m. recorded Noted abrasion to right wrist from soft cast rubbing. Area scab intact at this time. The physician returned the fax on [DATE] at 2:07 p.m., and directed staff monitor the area and update the physician with changes. A Skin/Wound Assessment form completed on [DATE] by Staff B described a scabbed abrasion that measured 0.8 centimeters (cm) by 1.5 cm by 0.8 cm, without drainage or symptoms of infection, and skin around scab normal. A Nurses Note dated [DATE] at 5:41 p.m. by Staff C, LPN and Assistant Director of Nursing (ADON) documented the local general practice physician noted the abrasion to the resident's right wrist where her cast rubbed without new orders. A Nurses Note dated [DATE] at 3:27 a.m. by Staff D, LPN recorded Resident #1 continued to show signs and symptoms of restlessness. PRN Ativan utilized after non-pharmacological interventions exhausted, i.e. distraction, 1:1, repositioning, redirection. The Nurses Notes dated [DATE] at 9:36 a.m. by Staff A documented Resident #1 was alert and oriented to herself only. She continued to pick at the soft cast and an area to her wrist was warm to the touch. The local general practice physician rounded; he took a look at this and would come back to facility and recast the area with a shorter cast so we can treat the area. Staff placed a call to the resident's orthopedic surgeon and made a follow-up appointment. At 12:00 p.m., Staff A documented the local general practice physician returned to recast the resident's right arm. When the cast was removed there was an area about a quarter size opened with copious amounts of drainage noted. The doctor ordered the resident sent to the hospital emergency room (ER) for evaluation. A Hospital ER Physician Note dated [DATE] at 12:23 p.m. described that Resident #1 was treated for post-operative wound infection of right elbow, wound dehiscence, osteomyelitis (bone infection) and sepsis, and an ulcerated area on the ulnar aspect of the right wrist, with erythema (redness and swelling) and warmth, appeared as a pressure ulcer caused by the splint. The ER provider consulted with the orthopedic surgeon, and the resident transferred to another hospital under the care of the orthopedic surgeon on [DATE]. The Surgeon's Operative Report dated [DATE] documented Resident #1 received treatment for wound dehiscence of right elbow, exposed hardware of her right elbow and post fixation of a right elbow olecranon fracture. The surgery required and completed on [DATE] included a rotational flap of the anconeus muscle to cover the right elbow skin defect; complex closure of secondary wound dehiscence, right elbow; removal of deep hardware, right elbow and excision of infected olecranon bursa, right elbow. The resident required treatment with intravenous antibiotics at the hospital, where she remained until [DATE]. During interview on [DATE] at 9:47 a.m., Staff B, RN, Restorative Nurse stated that on [DATE] she took a photo of the resident's wrist wound, could tell it was from the cast because it was located in the area that rubbed the resident's arm when she flexed at the wrist. It was an intact scab, no drainage and not reddened, and Staff B put it on the list for the Wound Nurse to follow, sent a fax to the physician's clinic for treatment orders because it was a skin issue. The floor nurse could have called the surgeon, she had just updated the primary physician and wasn't a regular staff nurse there, but did fill in when a nurse was off sometimes. Staff B couldn't recall if she was a staff nurse that day or just helping out to get the information to the doctor (facility records revealed Staff B was the nurse assigned to the resident on the [DATE] 6 a.m. to 6 p.m. shift.) On [DATE] 11:36 a.m. Staff E, RN stated there was an area on the resident's right wrist that became sore. On [DATE], one of the local general practice physicians came to change the cast, when the cast was removed, there was a large amount of thick, yellow drainage from the elbow and the doctor ordered the resident transferred to the ER. During an interview on [DATE] at 6:21 a.m. Staff A stated the resident developed a sore on their right wrist. They cleaned it, padded it with dressings, when she cleansed it on [DATE] it became red. She checked to see when the resident's ortho follow-up appointment was, discovered it had not been scheduled, called that day and scheduled it. One of the local doctors was at the facility that day and she asked if they would look at the resident's arm and change the cast. When the doctor removed the cast there was a lot of drainage from the elbow, Staff A saw metal where the incision opened, and the doctor ordered staff to transfer the resident to the ER. Prior to that day, the resident picked at the soft cast and acted like she was trying to take it off. Staff A stated she did not notify the orthopedic surgeon of the wrist skin condition and need to revise the cast because the general practice physician was at the facility and agreed to change it. During interview on [DATE] at 8:27 a.m. Staff F, LPN, the facility's Wound Nurse stated she looked at the resident's wrist wound with Staff B, she thought it was a scabbed area, maybe dime-sized. Staff F thought the resident picked at it, and wasn't necessarily from the cast. When asked how the staff could have known sooner there was a problem under the resident's cast, Staff F stated staff could have called the orthopedic office and asked for clarification, to see if they were supposed to check the dressing under the cast, but staff would need an order to remove the soft cast to check the dressing. On [DATE] at 10:15 a.m. the Director of Nursing (DON) stated she didn't expect staff to take the cast off to check the resident's CMS and dressing, the staff should have called the orthopedic office for clarification of cast care and wound care orders for the resident's arm, and they didn't do that; they should have. Staff B faxed a local general practice MD, not the orthopedic doctor, about the wound on her wrist, at that time staff padded the area with dressings to protect the skin. There was an order faxed back from the doctor, but this wasn't entered as an order because it hadn't been double noted, that staff were to monitor the wrist abrasion and notify the physician of changes. When asked why staff wouldn't have notified the orthopedic surgeon about that condition, the DON stated the general practice MD (Medical doctor) group are often at the facility, staff felt comfortable with them, and the resident was assigned to one of them for all general orders. On [DATE], one of the local general practice physicians came to the facility for another resident, looked at Resident #1's arm and agreed to change the cast. There should have been some clarification of what to do with the soft cast on the resident's admission. The facility identified this issue on [DATE], made a past non-compliance Plan of Correction and educated staff on neurovascular assessments (CMS) and orders that weren't recorded on the resident's [DATE] admission (follow-up doctor appointment, clarification of care). During interview on [DATE] at 4:28 p.m., Staff G, RN, Clinic Manager at the resident's orthopedic surgeon's office stated she verified their Cast/Splint Care follow-up instruction sheet was in Resident #1's electronic hospital record, and it should have been sent with the resident upon her discharge to the facility, along with her other discharge orders. The instruction sheet directed them to call the orthopedic doctor if there was pain or problems associated with the cast. The resident was to have a follow-up appointment with their surgeon within two weeks of her [DATE] hospital discharge. The first time they heard from anyone at the facility was on [DATE] at 9:06 a.m., when staff called to set up the resident's follow-up appointment and made no mention of any problems or skin conditions. Staff G stated the first notice the clinic had of condition concerns came on [DATE] at 1:09 p.m. when a nurse from the local hospital ER called and urgently wanted the cell phone number for the orthopedic surgeon. The ER nurse described the resident's elbow wound as dehisced and infected, and wanted directions from the surgeon for urgent care. The orthopedic surgeon directed the resident's transfer to another hospital and the resident required surgery the following morning. The facility should have called if there were any problems, should have clarified care orders if they were uncertain, and should have assessed the resident's CMS per professional standards and documented that. The facility should have called them, and not a general practice physician, of the need to revise the resident's cast due to the cast causing skin injury to the resident's wrist. The facility's Medication and Treatment Orders policy, revised 7/16, directed staff that medications shall be administered only upon the written order of a person licensed and authorized to prescribe such medications in this state; the orders must be recorded on the Physician's Orders in the resident's electronic medical record and all orders are to be written, dated and signed by the person lawfully authorized to give such an order. The policy did not specify or direct an expectation that staff follow physician orders unless clarification required, and staff to clarify the order in such situations. The facility's Change in a Resident's Condition or Status policy, revised 2/21, directed staff: The nurse will notify the resident's attending physician or physician on call when there has been a (an) a. Discovery of injuries of an unknown source. b. Significant change in the resident's physical/emotional/mental condition. c. Need to alter the resident's medical treatment significantly. d. Specific instructions to notify the physician of changes in the resident's condition. The State Agency notified the facility of the Immediate Jeopardy on [DATE] at at 12:45 p.m. The Immediate Jeopardy situation started on [DATE]. The facility removed the Immediate Jeopardy on [DATE] through the following actions: Initiated staff education to all nurses that CMS assessments required when a resident has a cast or splint, physician orders should be specific and must address care requirements related to the cast or splint, dressing changes and wound care orders and when a resident has a cast or splint, staff to monitor skin conditions every shift and notify the Surgeon by phone the cast or splint has caused an abnormal skin condition. The DON or designee will be responsible to monitor that CMS checks are in place with accurate orders for removal or not removal of splint/cast; will complete audits of CMS checks, 4 audits per week for 4 weeks, then weekly for 2 months and will complete audits of surgeon notification with change in condition, 4 audits per week for 4 weeks, then weekly for 2 months. Residents admitted with splints/cast will be reviewed during their weekly SOC meeting for any changes observed and documented, and surgeon notification. The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education. 2. The [DATE] MDS assessment recorded Resident #6 entered the facility [DATE] with diagnoses that included renal insufficiency, diabetes and clavicle fracture (collar bone). The resident scored 12 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, indicating moderate cognitive and memory impairment. Resident #6 did not walk and required the extensive assistance of 2 staff to reposition in bed, to transfer, and with toilet use. Resident #6 required the assistance of one staff member with locomotion on and off the unit and with personal hygiene. The MDS documented she'd not had any pain during the 5 days that preceded the assessment. The resident required renal dialysis treatments before and during facility residence. Wound assessments on [DATE] by Staff H, LPN documented: a. Open lesion of right lateral calf that measured 5.5 cm by 1.9 cm, no depth, scant serous (yellow liquid) drainage. b. Left heel deep tissue injury (DTI) that measured 1.9 cm by 1.2 cm, without depth, surrounding skin normal colored and without drainage. c. Stage 2 pressure sore of the coccyx (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) that measured 0.8 cm by 0.6 cm, no depth, light serosanguinous (pink and yellow colored) drainage. d. Another Stage 2 pressure sore of the coccyx that measured 0.9 cm by 0.7 cm, no depth with light serous drainage. e. Stage 2 pressure sore of right calf that measured 1.6 cm by 2.9 cm, without depth, light serosanguinous drainage. Resident #6's [DATE] Physician orders instructed to to check her pain level every shift, administer acetaminophen (Tylenol, an over-the-counter analgesic) 650 milligrams (mg) administered oral 3 times daily and to apply oxygen continuously at 2 liters via nasal cannula. The resident's Wound Care Orders dated directed staff to apply Betadine to DTI on left heel daily, to cleanse area to right lower posterior leg with Normal Saline (NS), pat dry and cover with Tegaderm (clear adhesive dressing), change every 3 days and PRN (as needed) and to cleanse areas to the left and right buttocks with NS, pat dry and cover with Tegaderm, change every 3 days and PRN. A pressure related skin injury problem initiated on [DATE] on the resident's Nursing Care Plan directed staff to assess, record and monitor wound healing; measure length, width and depth where possible; assess and document status of wound perimeter; to apply pressure reducing cushion to her wheelchair, a pressure relieving/reducing device on bed (low loss air mattress; place pressure reducing boots to bilateral feet (Prevalon Boots) and to monitor for pain related to pressure injury. The resident's 6/22 and 7/22 Treatment Administration Records (TARs) revealed the following pain assessments, with a 0 to 10 pain scale used, 10 assigned to the worst possible pain: 6/24 6/25 6/26 6/27 6/28 6/29 6/30 7/1 7/2 7/3 7/4 7/5 Day shift 3 0 0 7 0 0 0 0 4 0 X Night shift 3 3 0 0 0 0 0 0 4 0 0 A Nurses Note on [DATE] at 11:10 a.m. by Staff H, LPN recorded that Resident #6 denied cough or shortness of breath, lungs clear to auscultation (LCTA), resident alert, pleasant and able to make needs known. A Nurses Note dated [DATE] at 9:31 a.m. by Staff I, RN recorded the resident's LCTA, capillary refill quick, no complaints of shortness of breath or cough. Assist of one with EZ-Stand (for transfer assistance) and wheelchair propelled by staff. On [DATE] at 9:55 a.m. Staff E, RN documented Resident #6 continued with an occasional non productive dry cough. She denied any shortness of breath and continued with oxygen at 2 liters nasal cannula (NC). LCTA. Resident #6 refused to wear Prevalon boots to bilateral feet. The resident had a low air loss mattress to her bed and pressure relief cushion in the wheel chair. Staff encourage Resident #6 to reposition. A Nurses Note dated [DATE] at 9:29 a.m. by Staff J, RN recorded Resident #6 as pleasant and cooperative with cares, she denied any shortness of breath and continued with oxygen at 2 liters NC. LCTA, dressing changed to right calf per orders. Resident #6 refused to wear Prevalon boots to bilateral feet. The resident had pitting edema to bilateral lower extremities reported to this nurse, right lower extremity without edema this shift, left lower extremity (LLE) with 3+ pitting edema (when thumb pressed on the skin surface with moderate pressure applied, a pit of 4 millimeters (mm) to 6 mm deep lasts as long as 60 seconds before resolved), the resident's legs were elevated in recliner. Resident #6 got up with the EZ stand for transfer to dialysis this morning. A Nurses Note on [DATE] at 11:50 p.m. by Staff K, LPN documented Resident #6 continued with 4+ pitting edema (when thumb pressed on the skin surface with moderate pressure applied, a pit of 8 mm deep lasts 2 to 3 minutes before resolved) to right lower extremity (RLE) and 3+ edema to LLE. The resident's RLE was weeping, red and warm. Staff covered the area with ABD pads (thick absorbent gauze dressings that measure 5 inches by 9 inches by 1/2 inch thick) and wrapped. The resident's right foot had purple bruising all around it. Resident #6 denied shortness of breath. LCTA. The resident reported pain of 10 out of 10 on the pain scale and her scheduled Acetaminophen was not effective with pain relief; the resident continued to ask for more pain medication. Staff encouraged her to elevate her BLE as much as possible. The resident had one Prevalon boot on the left foot but won't wear one on the right foot due to pain. Staff K documented she would continue to monitor. A Nurses Note dated [DATE] at 11:42 a.m. documented Resident #6 was found unresponsive, had CPR (cardiopulmonary resuscitation) in progress and staff alerted 911. The Dialysis Treatment Note dated [DATE] by Staff L, RN documented: Dialysis start time 10:46 a.m., stop time 2:18 p.m. Weight pre treatment 204.4 pounds, post treatment 199.5 pounds. Pre treatment legs with 2+ pitting edema, (when thumb pressed on skin with moderate pressure, a pit between 2 mm and 4 mm takes up to 15 seconds to rebound) no complaints of pain. Post treatment legs with 2+ pitting edema, no complaints. The Dialysis Treatment Note dated [DATE] Staff L, RN documented: Dialysis start time 10:39 a.m., stop time 2:18 p.m. Weight pre treatment 197.3 pounds, post treatment 193.8 pounds. Pre treatment legs with 3+ pitting edema, no complaints. Post treatment legs with 2+ pitting edema, no complaints. On [DATE], the Administrator provided the resident's wound photos obtained [DATE] in the resident's electronic record, that revealed the left heel had a medium violet colored area approximately 3 cm in size and identified as the DTI, with a 1 to 2 cm border of dark pinkish-red skin, and normal pink skin color throughout the sole and heel area outside of the pinkish-red border. Another photo of one of the wounds on the resident's right leg showed a portion of the top of the right foot that was a normal pink color. When copies of the resident's [DATE] wound photos were requested on [DATE], the Administrator stated they were a part of the facility's Quality Assurance Program and would not be provided. The resident's Responsible Party/Power of Attorney (POA) submitted a photo of the resident's right lower leg and foot taken on [DATE] that revealed most (at least 90 percent) of the top portion of the resident's right foot was a deep purple-reddish color, similar to a [NAME], and the foot extremely edematous. Interview on [DATE] at 9:53 a.m. with Staff K, LPN revealed she remembered Resident #6's foot looked purple, the resident had a lot of edema in her legs and complained of severe pain when she worked on [DATE]. Staff K did not notify the physician of the findings, they can call the hospital ER doctor on nights/weekends or holidays but the only order they ever gave was to send the resident to ER, or not even that and no other orders. Staff K did not notify the DON about the change of condition either. The resident's right foot looked different on [DATE] and she had a lot more edema, the resident couldn't say what happened to her foot and Staff K tried to figure out how her foot got bruised/purple. On [DATE] 11:36 a.m. Staff E, RN stated on the morning of [DATE] she heard a page for her to go to the resident's room STAT (as soon as possible). When she got there Staff F, LPN/Wound Nurse and the wound doctor had started CPR. When asked what she would do if a wound had worsened, or if a resident developed swelling, or warmth of skin and was new or worse, Staff E stated she would notify the physician. On weekends or evenings/nights, staff can call the hospital Hospitalist or the ER doctor for orders, that system has long been in place. On [DATE] at 8:27 a.m. Staff F stated she thought the resident's legs were edematous, and she initiated CPR on the resident one morning when she rounded with the Wound Doctor and found the resident had arrested. When asked what she would do if she thought a resident's legs were more edematous, or started weeping, she stated she would call the physician and that after hours they can call the ER doctor at the hospital for orders on any of the residents. During interview on [DATE] at 9:15 a.m., Staff L, RN, Dialysis Nurse stated the resident had pitting edema that was improved slightly be the end of the dialysis treatment cycle, she never had weeping edema in her legs, and if that was a new finding, the nurse should have notified the doctor. Staff L reviewed a photo of the resident's feet that showed her right foot dark purple colored and extremely edematous and Staff L stated she had never saw the resident's foot look like that and staff should have notified the physician of that. On [DATE] at 3:54 p.m. Staff J, RN stated that on [DATE], when she documented the resident's edema was worse, it's because that is what the previous nurse reported to her, it wasn't a new condition that she had identified. If she had identified a new condition, she would have called the doctor. On the weekends they have to call the ER doctor at the hospital. Staff J stated if a resident complained of pain 10 out of 10 on the pain scale, and pain meds didn't help or if there wasn't a pain med to give, she would call the MD, would not fax, and doesn't matter if it's a holiday, or weekend, or night shift, staff are supposed to notify the physician. During interview on [DATE] at 10:46 p.m., Staff H, LPN, when asked if a resident had worsened edema, or if their edema started weeping and the extremity warm to touch, or if a resident complained of pain 10 out of 10 on the pain scale that was new, Staff H stated those were all things that the physician should be notified of, and they called the ER doctor at the hospital on the evening/night shifts and on weekends for orders. On [DATE] at 10:15 a.m. the DON stated the physician group from the hospital were not on call, when there was a problem with a resident after 5 p.m. or on weekends/holidays, staff were supposed to call the ER doctor for orders and it's sort of a problem, the ER doctor doesn't know the resident, sometimes they don't give orders, other times they want the resident sent to the ER so they can assess them. When asked what she expected staff to do for the symptoms described in the Nursing Progress Notes by Staff K on [DATE], the DON stated the nurse should have notified the ER doctor for orders, and the nurse had not notified her of the resident's condition changes. The DON stated they just started and were monitoring for staff notifying physicians when changes in conditions were identified, on one of their Past Non Compliance Plans of Correction (POC). When asked what that POC was related to, the DON stated it was for Resident #6 and similar residents. When asked why that wasn't implemented sooner, if it was related to the resident's cardiac arrest and death on the morning of [DATE], the DON stated they had just recently became aware of the situation. During interview on [DATE] at 1:05 p.m. the resident's POA stated Resident #6 was at the hospital for several weeks before she transferred to the nursing home, the POA visited her frequently and saw her legs while there, the resident complained of some pain in her legs at times, but it varied and managed with medication. When she transferred to the nursing home, the first couple of days were okay, then her leg sores and her pain got worse. She saw the resident at the facility [DATE], her feet were swollen but normal colored. On [DATE], the resident called and said her right leg really hurt, another family member visited the resident that day, noticed the resident's right foot was dark purple and took a picture of it. On [DATE], Resident #6 called and said they were in horrible pain, wanted the nurse to check on her, the POA called the nurse at the facility and asked her to check on the resident and call back with an update; the nurse never called back. The resident called and asked if they called the nurse because they hadn't come to assess her. Later that day the resident said 2 nurses came in to her room and asked her what happened. The POA didn't hear anything from the staff about the resident's pain or condition on [DATE], early the next morning the facility called and said they were doing CPR and sending her to the hospital. Resident #6 expired when they got to the hospital.