**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 36 residents, with 10 residents selected for review, including two residents reviewed for neglect. Based on observation, interview, and record review, the facility failed to conduct a thorough assessment of one Resident (R)1 with a change in condition. The facility failed to notify the physician when R1 did not have an increase in urinary output following an increase in physician ordered diuretic medication (medication to promote the formation and excretion of urine) on [DATE]. The facility failed to notify the physician on [DATE] when the resident lacked urinary output for greater than 24 hour and complained of difficulty breathing. On [DATE] the facility further failed to provide ongoing assessments of R1 by a licensed nurse after the resident had complaints of difficulty breathing, and inability to obtain oxygen saturation level (the percentage of oxygen in the blood), when the resident had coolness of his hands and arms after application of a warm blanket, and after application of oxygen for over four hours from 01:15 PM to approximately 05:52 PM. The facility provided cardio-pulmonary resuscitation (CPR- the manual application of chest compressions and ventilation to patients in cardiac arrest) when staff found the resident unresponsive until medical emergency services (EMS) arrived. The resident died on [DATE] at 06:38 PM. The lack of ongoing assessments and monitoring placed all residents in the facility in immediate jeopardy. Findings included: - The Face Sheet for Resident (R)1 included diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), lymphedema (tissue swelling as a result of blockage in the lymphatic system), cirrhosis (chronic degenerative disease of the liver) without ascites (excess abdominal fluid), infection and inflammatory reaction due to indwelling urethral catheter (tube inserted into the bladder to drain urine), and benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections) with lower urinary tract symptoms. The Orders tab for R1 included these orders, however lacked an order for oxygen: 1. Flomax (medication used to treat BPH, 0.4 milligrams (mg), by mouth, daily for BPH with lower urinary tract systems, ordered on [DATE]. 2. Spironolactone (medication used to treat fluid retention), 100 mg, by mouth, once a day, for edema, ordered on [DATE]. 3. Torsemide (medication used to treat fluid retention caused by CHF, kidney failure, or liver disease), 20 mg, by mouth, twice a day, at 07:00 AM and 02:00 PM, must take seven hours apart, for edema, ordered on [DATE]. 4. Urinary catheter, size 16 French, change every 30 days, on the first of the month, ordered on [DATE], for urinary tract infection (UTI). 5. Chart catheter output, every shift, three times a day, for infection and inflammatory reaction due to indwelling catheter, ordered on [DATE]. 6. Flush urinary catheter, as needed for clogging due to sediment, for urinary tract infection, ordered on [DATE]. 7. Sodium chloride, one gram, by mouth, once a day, ordered on [DATE]. The admission Minimum Data Set dated [DATE], revealed R1 admitted to the facility on [DATE]. He had clear speech, could make himself understood, and could understand others. He had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. R1 did not have any behavior symptoms or rejection of care. He required extensive assistance of two or more staff for bed mobility and was dependent of two or more staff for transfers and toilet use. R1 had an indwelling catheter in place, sepsis (systemic infection), and a history of a urinary tract infection (UTI) in the past 30 days. He received a diuretic medication seven days and an antibiotic two days of the seven-day assessment period. The Activities of Daily Living (ADL's) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated [DATE], revealed R1 required extensive to total assistance with ADL's and had several co-morbidities that made it difficult for him to do much. The Urinary Incontinence and Indwelling Catheter CAA dated [DATE], revealed R1 had a catheter, admitted with diagnosis of UTI, and was on an antibiotic (medication to fight bacterial infections). The Dehydration/Fluid Maintenance CAA dated [DATE], revealed R1 was aware of his own thirst, could grasp a cup and get his own drink, was on a 2,000 milliliter (ml) fluid restriction, and required two diuretics (medication to promote the formation and excretion of urine): spironolactone and torsemide. The Care Plan dated [DATE], revealed R1 required total assistance from two or more staff for toileting. The care plan lacked notification to staff that R1 had an indwelling catheter and/or management of the catheter, lacked presence of edema, and lacked medications used to treat edema. The Progress Notes dated [DATE] at 10:44 AM, revealed Consultant Physician Extender GG was at the facility, saw R1, and gave verbal orders for therapy to assess him for lymphedema wraps and if the resident did not qualify, apply ACE (all cotton elastic) wraps in the am and take them off at HS (hour of sleep) . increase torsemide (medication to promote the formation and excretion of urine) to 40 milligrams (mg), twice daily, for five days, then decrease back to 20 mg daily. The physician Progress Notes dated [DATE], revealed this was an annual wellness visit. R1 reported to Consultant GG Physician Extender that he felt well, they discussed his full code status (when the heart stopped beating and/or breathing stopped, all resuscitation procedures were to be provided to keep the person alive) and risks/benefits, and R1 wished to remain with a full code status. The nursing staff reported progression of lower extremity edema and felt he would benefit from a medication adjustment at this time. During exam, the resident had no shortness of breath, his lung sounds were clear, his abdomen was soft and nontender, and he had bilateral (both) lower extremity edema at 3+ (five to six millimeters of depression to skin when pressed with a rebound time of 10-30 seconds). He received spironolactone (medication to promote the formation and excretion of urine), 100 mg, by mouth, every morning, and torsemide, 20 mg, by mouth twice daily. The Progress note included to increase the torsemide to 40 mg, by mouth, twice daily, for five days, then resume 20 mg, by mouth twice daily, for CHF. The Medication Administration Record (MAR) dated 11/01-[DATE], revealed R1 received torsemide, 40 mg, by mouth on [DATE] at 05:00 PM dosing time, [DATE] at 08:00 AM dosing time, [DATE], he refused the 05:00 PM dose, received both doses on [DATE] and [DATE]. On [DATE] he received the 08:00 AM dose, but did not receive the dose at 05:00 PM Due to condition documented at 04:10 PM by Certified Medication Aide (CMA) S. The Urine Output log revealed on [DATE] at 05:26 AM, R1 had 100 ml of urine output. On [DATE] at 10:31 PM, he had 100 ml of output. On [DATE] at 05:13 AM, zero output, [DATE] at 05:30 AM, he had 100 ml output. The urine output tracking log lacked documentation of output again until [DATE] at 06:14 AM, for a total of 13 hours and 14 minutes. The Urine output revealed on [DATE] at 06:14 AM, R1 had 100 ml of urine output. The Progress Note dated [DATE] at 05:19 PM, revealed another nurse changed R1's catheter and had output noted at that time. However, the note lacked the amount of urine output with the catheter insertion. The Progress Note dated [DATE] at 09:24 AM, revealed the off-going charge nurse reported to Administrative Nurse E that R1's catheter was changed [DATE] and since that time there had been minimal output. Administrative Nurse E assessed R1 for urine output and Noted urine in catheter tubing. Administrative Nurse E flushed the catheter and met no resistance. The note lacked the amount of fluid returned after flushing the catheter. The Urine Output log revealed on [DATE] at 01:53 PM, R1 had 100 ml of urine output. The Progress Note dated [DATE] at 05:20 PM, revealed R1 complained of penile pain related to the catheter and stated it felt like the catheter was partially out. Administrative Nurse E noted there was urine in the tubing and flushed the catheter without difficulty. R1 continued to complain of pain. Administrative Nurse E removed the urinary catheter and inserted a new catheter and there was no urine output with the insertion of a new catheter. When Administrative Nurse E inflated the urinary catheter balloon (located at the tip of the catheter behind the drainage eyelets, inflated after a urinary catheter is properly placed to help keep the tubing seated in the bladder) R1 complained of pain. The note included Administrative Nurse E would monitor R1 for urine output and complaints of pain. The Urine output log revealed no further urine output documented from [DATE] at 01:53 PM until [DATE] at 01:44 AM, which was documented as zero urinary output. The facility documented zero urinary output again at 04:39 AM. The Progress Note dated [DATE] at 04:40 AM revealed R1 had no urine output since the catheter had been changed and he denied discomfort. Administrative E flushed the catheter without difficulty and was unable to palpate for bladder distention due to size of abdomen. The Progress Note dated [DATE] at 11:07 AM, revealed Administrative Nurse D was asked to check on R1 by Licensed Nurse (LN) G who was the charge nurse. The note revealed R1 complained of not feeling good but did not elaborate and was not wanting to talk, which was not unusual for him. Administrative Nurse D assessed his lungs to be clear, did not appear to be short of breath, did not appear to be in distress, and was unable to obtain his oxygen saturation measurement on his fingers or his earlobe. Staff applied warm packs and an extra blanket to attempt to warm his fingers, without success. The assessment lacked any measurement of vital signs (blood pressure, pulse, respirations, temperature), lacked further head to toe assessment including assessment of urinary function, and lacked physician notification. The Progress Note date [DATE] at 01:20 PM, revealed after evaluating the resident again, staff requested to send the resident to the emergency room (ER) and noted R1's hands and arms were cool to touch despite warming attempts and now stated he was short of breath although he did not appear to be. Staff were unable to measure the resident's oxygen saturation level and notified family. R1's lungs remained clear, and the resident's oxygen was at three liters-per-minute. The family member attempted to call R1's cell phone, but R1 was unable to speak to the family member, so Administrative Nurse D spoke with the family member and the family member wished not to call EMS and to elevate the head of R1's bed instead. R1 was agreeable to this and the staff elevated the head of his bed. The note lacked measurement of vital signs and physician notification. The Urine output log revealed on [DATE] at 02:20 PM the resident had zero urinary output. R1 lacked urinary output from [DATE] at 01:53 PM through [DATE] at 02:20 PM, a time span greater than 24 hours. The facility further failed to notify R10's physician during this time. Review of the facility's video footage for [DATE], along with Administrative Staff F, revealed an unidentified staff member carrying an oxygen bottle to R1's room at 01:01 PM, Administrative Nurse D exited R1's room at 01:15 PM, and no further licensed nurses entered his room until approximately 05:52 PM (over 4.5 hours later) when LN G and LN H entered the room. The video footage had intervals of skipping from 20 seconds to several minutes during the time frame reviewed. The Progress Notes lacked any further assessment of the resident until documentation at 06:38 PM, which revealed LN G and LN H were notified R1's vital signs has ceased. LN G and LN H performed assessments and a Certified Nurse Aid (CNA) start CPR. EMS notified and came to the facility and confirmed the resident's vital signs had ceased. During an interview on [DATE] at 11:27 AM, LN G stated R1 passed away during change of shift on [DATE]. LN G stated he was the off-duty nurse at that time and called 911, while CMA S and LN H (the on-coming nurse), and was not sure if there was anyone else, that performed CPR. LN G stated R1 reported to him he could not breathe during his shift. Administrative Nurse D and LN G checked R1's oxygen saturation, but R1's hands were cold, and they could not get them warm enough to get an accurate reading, so Administrative Nurse D took over. R1's lungs were clear and Administrative Nurse D reported those findings to a family member and had asked if staff could send R1 out to ER, but the family member wanted to hold off and have him re-evaluated in a little bit. LN G stated the family member never called back. LN G stated around 05:15-05:30 PM, the staff turned R1, he wanted a drink at that time, and then around 06:15 PM the staff went to deliver R1's hall tray and found him unresponsive. LN G stated R1 had a catheter and the staff monitored output, the aides would document the output every shift and the nurses would document it as well. The aides would empty the catheter bags once a shift towards the end of their shift and LN G stated he could not recall if R1 had a change in his urinary output that day. On [DATE] at 01:24 PM, R1's family member stated on [DATE] at approximately 02:00 PM or 2:30 PM, the facility was to call him back in an hour after staff assessed the resident. The family member stated he never heard anything back and assumed everything was okay. The family stated the facility reported the resident complained of chest pain and difficulty breathing, but his lungs sounded good, and he appeared to be breathing fine. Staff informed the family member that the resident's hands were to too cold to get an oxygen saturation reading. There was not a sense of urgency when talking to the facility about his condition and he did not realize that going to the hospital was recommended. The facility was going to sit the resident up and call the family back in an hour. The family member stated he did not receive a call until the facility's nurse called to say the resident had passed away. On [DATE] at 08:54 AM, LN H stated she worked on [DATE], then was off duty until [DATE] for the 06:00 PM shift. LN H stated she did not notice any abnormal swelling on [DATE] and Consultant Physician Extender GG had seen R1 on [DATE]. LN H stated she was trying to see if R1's catheter situation had been addressed and low output was normal for him around 100-300 ml per shift. R1 would drink water during her shift and the CNA's would empty the catheter. The catheters were emptied as needed, but at least once a shift at the end of the shift. LN H stated she was getting report from LN G when one of the CNA's said R1 was not breathing, so her and LN G went to assess R1, and he lacked vital signs. LN G went to check his record while CPR was started by CMA S and EMS contacted. Compressions continued until EMS took over. LN H stated she was not aware of any difficulty with compressions because at that point she was at the desk and LN G was assisting. LN G called 911 and notified a family member. On [DATE] at 10:28 AM, Administrative Nurse E stated she recalled R1 having no urinary output and did not recall if the physician was notified or not. After checking documentation, Administrative Nurse E stated she did not notify the doctor and assumed the day shift would do so as she would not notify the physician in the middle of the night for that reason, and passed it on in report to LN G. Administrative Nurse E stated R1's output fluctuated between 300-600 ml but did not specify per shift or day, the charge nurse monitored output, and confirmed his output from 11/05-[DATE] was not appropriate with the increase in the torsemide on [DATE], and Consultant Physician Extender GG should have been notified. On [DATE] at 11:16 AM, Administrative Nurse D stated the nurses were responsible for monitoring urinary output and the CNA's emptied and reported the amount to the charge nurse. Administrative Nurse D stated she would expect the nurse to notify the physician if there was little or no urinary output present and would expect an increase in output with administration of Torsemide. Administrative Nurse D stated she was under the impression someone notified the physician of low urine output. Administrative Nurse D reported on [DATE], LN G was the charge nurse and at approximately 11:07 AM asked her to go look at R1 as he could not get R1's oxygen saturation, his hands were cold, he did not feel good, and R1 would not talk to LN G, so she went down to his room to assess him. R1 had on oxygen when she went to assess him, his lungs were clear, no shortness of breath, his hands were really cold, so she did warm packs and warm blankets on his hands and arms to try and warm them up. R1 would not talk to her, and she was not able to get a measurement of his oxygen saturation. Administrative Nurse D stated she contacted Consultant Physician Extender GG around noonish and was told he could be sent to ER if we needed to, but the whole time R1 did not want to go. Administrative Nurse D stated she went back around 01:20 PM and his hands and arms were cold and he refused to go to ER so she then called the family member who stated if R1 did not want to go do not make him, but try to raise the head of the bed to see if that helps, and did not believe when she talked to the family member she specifically said they had an order to send R1 to the ER. Administrative Nurse D stated she was not aware that R1 lacked urinary output and did not talk to the physician extender about urinary output, and stated she was in and out of the room that afternoon to check on R1 until she left, which was usually around 04:00 PM. Administrative Nurse D stated LN G should have checked his vital signs and would expect staff to document vital signs. On [DATE] at 01:14 PM, Consultant Physician Extender GG reported on her visit on [DATE], R1 had more swelling in his legs, so she increased the diuretic, and the staff had reported his edema was gradually increasing, and staff elevated his legs. Consultant Physician Extender GG stated she expected an increase in urinary output with the increase in the diuretic and should have been notified of lack of increase in the urine output and lack of urine output, as that was a problem. Consultant Physician Extender GG stated the facility should have made her aware of any urinary output less than 30 ml in an hour. Consultant Physician Extender GG stated she was not aware of R1's change of condition on [DATE]. If staff would have notified the physician extender, she would have given the order to send him to the ER. On [DATE] at 01:47 PM, CMA R stated CNAs emptied the catheters at least once on an eight-hour shift, and some nurses wanted the output documented in the electronic record and some wanted it on a piece of paper so they could see it and document the output themselves. CMA R stated staff should report to the nurse if there was lack of urine output or change in the urine color. On [DATE] at 02:51 PM CNA M reported she recalled on [DATE], R1 had 100 ml of urine output the whole shift. He liked tea, and she made him a big mug and he drank all of what was in the mug. On [DATE], she could feel fluid when rolling R1 and holding him over, it was leaving indentions where she would touch his leg and told the nurse. She reported the resident had the same edema on [DATE]. CNA M stated R1 was breathing okay on [DATE] and he would change the level of the head of the bed and liked it lower, but not flat. She did not notice any increase in his abdominal swelling however, his scrotum was swollen too, so she arranged the catheter tubing to see if that would improve urinary output and placed his legs on a pillow to elevate his legs. On [DATE] at 03:10 PM, CNA O stated on [DATE] she came in at 02:00 PM and when exiting another resident room, she glanced at R1 and noticed his head of bed was straight up and thought that was weird as he never liked to sit up straight. The resident had an oxygen concentrator in the room, which was new. CNA O offered him a drink as his mouth was really dry and R1 shook his head no. He was trying to talk and seemed like he was trying to catch his breath. The resident's nasal cannula was off, and staff placed the resident's oxygen nasal cannula back on him. CNA O stated she did not tell the nurse at that time as she felt the nurse was probably already aware since R1 had oxygen in place. CNA O stated his hand was cold and had noticed before that day his edema was real bad. CNA O stated when staff would roll R1 over and hold him, fingerprints would stay in his skin and be that way for quite some time to his legs and his back. CNA O stated on [DATE] or [DATE], he was hardly having any urinary output and it was a little bloody and she reported she notified the nurse. CNA O stated his output was around 100 ml, but he was still drinking the same amount as usual. On [DATE] at 04:14 PM, CMA S stated on [DATE], R1 took his morning medication, but not his afternoon ones, because he was very out of it that afternoon and had a hard time breathing. He was on oxygen. CMA S stated she prepared his afternoon medications, she was having a hard time understanding what he was saying, and his voice was raspy and stated this was not normal for him at all. CMA S stated she told LN G he was having a hard time breathing and then talked to Administrative Nurse D, and asked if anyone had been called as she did not think he was doing well and Administrative Nurse D told her she had called a family member and there was a little decline, and R1 did not want to go to the hospital so the family member said to respect his wishes and do not send him. CMA S stated that was probably around noon. CMA S stated she saw him again around 04:00 PM to 05:00 PM, and R1 was coherent and said thank you but could not get any other words out, and he did not take his medications at that time. CMA S stated while she was counting medications with the nurse, a staff member reported R1 was unresponsive. CMA S stated she started CPR and when she gave the first compression it sounded like water like he was completely full of fluid. CMA S stated she provided CPR until EMS arrived and took over. CMA S stated the week before she had emptied R1's catheter and his urine had been cloudy and thick, like sediment and pus and stated she had reported that to the charge nurse. The facility's policy for Edema dated [DATE], revealed the current primary care provider would be notified immediately of any shortness of breath, difficulty breathing, or chest pain as these can be signs of pulmonary edema, which requires prompt treatment. The staff were to notify the primary care provider of any new or worsening signs and symptoms of edema and follow recommendations. The facility policy PCP (primary care physician) Notification of Change dated [DATE] included to observe and report significant change in condition and included to monitor resident's condition frequently until stable. The facility failed to conduct a thorough assessment of R1 with a change in condition. The facility failed to notify the physician when R1 did not have an increase in urinary output following an increase in physician ordered diuretic medication on [DATE]. The facility failed to notify the physician on [DATE] when the resident lacked urinary output for greater than 24 hour and complained of difficulty breathing. On [DATE] the facility further failed to provide ongoing assessments of R1 by a licensed nurse after the resident had complaints of difficulty breathing, and inability to obtain oxygen saturation level, when the resident had coolness of his hands and arms after application of a warm blanket, and after application of oxygen for over four hours from 01:15 PM to approximately 05:52 PM. The facility provided CPR when staff found the resident unresponsive until medical emergency services (EMS) arrived. The resident died on [DATE] at 06:38 PM. The lack of ongoing assessments and monitoring placed all residents in the facility in immediate jeopardy. On [DATE] at 01:55 PM, Administrative Staff A was informed the residents were in immediate jeopardy and was provided the Immediate Jeopardy Template for failure to conduct a thorough assessment with a change in condition, failure to notify physician with little and lack of output following an increase in diuretic medication, and failure to provide further ongoing assessments of R1 after his complaint of difficulty breathing and inability to measure his oxygen saturation level. The facility removed the immediate jeopardy on [DATE] at 06:30 PM when they completed the following: 1. The physician and/or nurse practitioner or physician's assistant will be notified of significant changes in a resident's condition. If after hours, call their cell phone. If no answer, call the hospital and ask the operator to page the physician and/or nurse practitioner or physician's assistant or the alternate physician that is taking call for the resident's primary care provider. 2. If a resident experiences any significant change and they are not on Hospice Palliative Care, or skilled End of Life, the resident will be automatically sent to the ER. admission packet will be modified for new admissions to state that fact. All current residents will receive and sign an addendum to the admission Agreement. 3. All staff will be in-serviced and trained on the change of practice. Immediate in-service will start on [DATE] and be completed on [DATE]. Completion of staff in-service was [DATE] at 06:30 PM 4. The daily skilled charting observation form in Matrix had been updated to include change of condition charting, which includes the mandatory inclusion of vital signs, PCP notification, and urinary output. This will go into effect immediately and will include any skilled resident or any resident that has had a change in condition. 5. A focused QAPI meeting addressing the finding was held with Administrator, Director of Nursing and Medical Director in attendance on [DATE] The facility provided an acceptable plan for removal of the immediate jeopardy on [DATE] at 06:00 PM. the survey team validated the immediate jeopardy was removed on [DATE] at 06:30 PM following the facility's implementation of the plan for removal of the immediate jeopardy. This deficient practice remained at a scope and severity of J (a situation in which immediate corrective action is necessary because of the likeliness to cause serious injury, harm, impairment, or death) and was lowered to a scope and severity of G (isolated with actual harm) following the removal of the immediate jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 36 residents, with 10 residents selected for review. Based on observation, interview, and record review, the facility failed to conduct a thorough assessment of one Resident (R)1 with a change in condition. The facility failed to notify the physician when R1 did not have an increase in urinary output following an increase in physician ordered diuretic medication (medication to promote the formation and excretion of urine) on [DATE]. The facility failed to notify the physician on [DATE] when the resident lacked urinary output for greater than 24 hour and complained of difficulty breathing. On [DATE] the facility further failed to provide ongoing assessments of R1 by a licensed nurse after the resident had complaints of difficulty breathing, and inability to obtain oxygen saturation level (the percentage of oxygen in the blood), when the resident had coolness of his hands and arms after application of a warm blanket, and after application of oxygen for over four hours from 01:15 PM to approximately 05:52 PM. The facility provided cardio-pulmonary resuscitation (CPR- the manual application of chest compressions and ventilations to patients in cardiac arrest) when staff found the resident unresponsive until medical emergency services (EMS) arrived. The resident died on [DATE] at 06:38 PM. The lack of ongoing assessments and monitoring placed all residents in the facility in immediate jeopardy. Findings included: - The Face Sheet for Resident (R)1 included diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), lymphedema (tissue swelling as a result of blockage in the lymphatic system), cirrhosis (chronic degenerative disease of the liver) without ascites (excess abdominal fluid), infection and inflammatory reaction due to indwelling urethral catheter (tube inserted into the bladder to drain urine), and benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections) with lower urinary tract symptoms. The Orders tab for R1 included these orders, however lacked an order for oxygen: 1. Flomax (medication used to treat BPH, 0.4 milligrams (mg), by mouth, daily for BPH with lower urinary tract systems, ordered on [DATE]. 2. Spironolactone (medication used to treat fluid retention), 100 mg, by mouth, once a day, for edema, ordered on [DATE]. 3. Torsemide (medication used to treat fluid retention caused by CHF, kidney failure, or liver disease), 20 mg, by mouth, twice a day, at 07:00 AM and 02:00 PM, must take seven hours apart, for edema, ordered on [DATE]. 4. Urinary catheter, size 16 French, change every 30 days, on the first of the month, ordered on [DATE], for urinary tract infection (UTI). 5. Chart catheter output, every shift, three times a day, for infection and inflammatory reaction due to indwelling catheter, ordered on [DATE]. 6. Flush urinary catheter, as needed for clogging due to sediment, for urinary tract infection, ordered on [DATE]. 7. Sodium chloride, one gram, by mouth, once a day, ordered on [DATE]. The admission Minimum Data Set dated [DATE], revealed R1 admitted to the facility on [DATE]. He had clear speech, could make himself understood, and could understand others. He had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. R1 did not have any behavior symptoms or rejection of care. He required extensive assistance of two or more staff for bed mobility and was dependent of two or more staff for transfers and toilet use. R1 had an indwelling catheter in place, sepsis (systemic infection), and a history of a urinary tract infection (UTI) in the past 30 days. He received a diuretic medication seven days and an antibiotic two days of the seven-day assessment period. The Activities of Daily Living (ADL's) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated [DATE], revealed R1 required extensive to total assistance with ADL's and had several co-morbidities that made it difficult for him to do much. The Urinary Incontinence and Indwelling Catheter CAA dated [DATE], revealed R1 had a catheter, admitted with diagnosis of UTI, and was on an antibiotic (medication to fight bacterial infections). The Dehydration/Fluid Maintenance CAA dated [DATE], revealed R1 was aware of his own thirst, could grasp a cup and get his own drink, was on a 2,000 milliliter (ml) fluid restriction, and required two diuretics (medication to promote the formation and excretion of urine): spironolactone and torsemide. The Care Plan dated [DATE], revealed R1 required total assistance from two or more staff for toileting. The care plan lacked notification to staff that R1 had an indwelling catheter and/or management of the catheter, lacked presence of edema, and lacked medications used to treat edema. The Progress Notes dated [DATE] at 10:44 AM, revealed Consultant Physician Extender GG was at the facility, saw R1, and gave verbal orders for therapy to assess him for lymphedema wraps and if the resident did not qualify, apply ACE (all cotton elastic) wraps in the am and take them off at HS (hour of sleep) . increase torsemide (medication to promote the formation and excretion of urine) to 40 milligrams (mg), twice daily, for five days, then decrease back to 20 mg daily. The physician Progress Notes dated [DATE], revealed this was an annual wellness visit. R1 reported to Consultant GG Physician Extender that he felt well, they discussed his full code status (when the heart stopped beating and/or breathing stopped, all resuscitation procedures were to be provided to keep the person alive) and risks/benefits, and R1 wished to remain with a full code status. The nursing staff reported progression of lower extremity edema and felt he would benefit from a medication adjustment at this time. During exam, the resident had no shortness of breath, his lung sounds were clear, his abdomen was soft and nontender, and he had bilateral (both) lower extremity edema at 3+ (five to six millimeters of depression to skin when pressed with a rebound time of 10-30 seconds). He received spironolactone (medication to promote the formation and excretion of urine), 100 mg, by mouth, every morning, and torsemide, 20 mg, by mouth twice daily. The Progress note included to increase the torsemide to 40 mg, by mouth, twice daily, for five days, then resume 20 mg, by mouth twice daily, for CHF. The Medication Administration Record (MAR) dated 11/01-[DATE], revealed R1 received torsemide, 40 mg, by mouth on [DATE] at 05:00 PM dosing time, [DATE] at 08:00 AM dosing time, [DATE], he refused the 05:00 PM dose, received both doses on [DATE] and [DATE]. On [DATE] he received the 08:00 AM dose, but did not receive the dose at 05:00 PM Due to condition documented at 04:10 PM by Certified Medication Aide (CMA) S. The Urine Output log revealed on [DATE] at 05:26 AM, R1 had 100 ml of urine output. On [DATE] at 10:31 PM, he had 100 ml of output. On [DATE] at 05:13 AM, zero output, [DATE] at 05:30 AM, he had 100 ml output. The urine output tracking log lacked documentation of output again until [DATE] at 06:14 AM, for a total of 13 hours and 14 minutes. The Urine output revealed on [DATE] at 06:14 AM, R1 had 100 ml of urine output. The Progress Note dated [DATE] at 05:19 PM, revealed another nurse changed R1's catheter and had output noted at that time. However, the note lacked the amount of urine output with the catheter insertion. The Progress Note dated [DATE] at 09:24 AM, revealed the off-going charge nurse reported to Administrative Nurse E that R1's catheter was changed [DATE] and since that time there had been minimal output. Administrative Nurse E assessed R1 for urine output and Noted urine in catheter tubing. Administrative Nurse E flushed the catheter and met no resistance. The note lacked the amount of fluid returned after flushing the catheter. The Urine Output log revealed on [DATE] at 01:53 PM, R1 had 100 ml of urine output. The Progress Note dated [DATE] at 05:20 PM, revealed R1 complained of penile pain related to the catheter and stated it felt like the catheter was partially out. Administrative Nurse E noted there was urine in the tubing and flushed the catheter without difficulty. R1 continued to complain of pain. Administrative Nurse E removed the urinary catheter and inserted a new catheter and there was no urine output with the insertion of a new catheter. When Administrative Nurse E inflated the urinary catheter balloon (located at the tip of the catheter behind the drainage eyelets, inflated after a urinary catheter is properly placed to help keep the tubing seated in the bladder) R1 complained of pain. The note included Administrative Nurse E would monitor R1 for urine output and complaints of pain. The Urine output log revealed no further urine output documented from [DATE] at 01:53 PM until [DATE] at 01:44 AM, which was documented as zero urinary output. The facility documented zero urinary output again at 04:39 AM. The Progress Note dated [DATE] at 04:40 AM revealed R1 had no urine output since the catheter had been changed and he denied discomfort. Administrative E flushed the catheter without difficulty and was unable to palpate for bladder distention due to size of abdomen. The Progress Note dated [DATE] at 11:07 AM, revealed Administrative Nurse D was asked to check on R1 by Licensed Nurse (LN) G who was the charge nurse. The note revealed R1 complained of not feeling good but did not elaborate and was not wanting to talk, which was not unusual for him. Administrative Nurse D assessed his lungs to be clear, did not appear to be short of breath, did not appear to be in distress, and was unable to obtain his oxygen saturation measurement on his fingers or his earlobe. Staff applied warm packs and an extra blanket to attempt to warm his fingers, without success. The assessment lacked any measurement of vital signs (blood pressure, pulse, respirations, temperature), lacked further head to toe assessment including assessment of urinary function, and lacked physician notification. The Progress Note date [DATE] at 01:20 PM, revealed after evaluating the resident again, staff requested to send the resident to the emergency room (ER) and noted R1's hands and arms were cool to touch despite warming attempts and now stated he was short of breath although he did not appear to be. Staff were unable to measure the resident's oxygen saturation level and notified family. R1's lungs remained clear, and the resident's oxygen was at three liters-per-minute. The family member attempted to call R1's cell phone, but R1 was unable to speak to the family member, so Administrative Nurse D spoke with the family member and the family member wished not to call EMS and to elevate the head of R1's bed instead. R1 was agreeable to this and the staff elevated the head of his bed. The note lacked measurement of vital signs and physician notification. The Urine output log revealed on [DATE] at 02:20 PM the resident had zero urinary output. R1 lacked urinary output from [DATE] at 01:53 PM through [DATE] at 02:20 PM, a time span greater than 24 hours. The facility further failed to notify R10's physician during this time. Review of the facility's video footage for [DATE], along with Administrative Staff F, revealed an unidentified staff member carrying an oxygen bottle to R1's room at 01:01 PM, Administrative Nurse D exited R1's room at 01:15 PM, and no further licensed nurses entered his room until approximately 05:52 PM (over 4.5 hours later) when LN G and LN H entered the room. The video footage had intervals of skipping from 20 seconds to several minutes during the time frame reviewed. The Progress Notes lacked any further assessment of the resident until documentation at 06:38 PM, which revealed LN G and LN H were notified R1's vital signs has ceased. LN G and LN H performed assessments and a Certified Nurse Aid (CNA) start CPR. EMS notified and came to the facility and confirmed the resident's vital signs had ceased. During an interview on [DATE] at 11:27 AM, LN G stated R1 passed away during change of shift on [DATE]. LN G stated he was the off-duty nurse at that time and called 911, while CMA S and LN H (the on-coming nurse), and was not sure if there was anyone else, that performed CPR. LN G stated R1 reported to him he could not breathe during his shift. Administrative Nurse D and LN G checked R1's oxygen saturation, but R1's hands were cold, and they could not get them warm enough to get an accurate reading, so Administrative Nurse D took over. R1's lungs were clear and Administrative Nurse D reported those findings to a family member and had asked if staff could send R1 out to ER, but the family member wanted to hold off and have him re-evaluated in a little bit. LN G stated the family member never called back. LN G stated around 05:15-05:30 PM, the staff turned R1, he wanted a drink at that time, and then around 06:15 PM the staff went to deliver R1's hall tray and found him unresponsive. LN G stated R1 had a catheter and the staff monitored output, the aides would document the output every shift and the nurses would document it as well. The aides would empty the catheter bags once a shift towards the end of their shift and LN G stated he could not recall if R1 had a change in his urinary output that day. On [DATE] at 01:24 PM, R1's family member stated on [DATE] at approximately 02:00 PM or 2:30 PM, the facility was to call him back in an hour after staff assessed the resident. The family member stated he never heard anything back and assumed everything was okay. The family stated the facility reported the resident complained of chest pain and difficulty breathing, but his lungs sounded good, and he appeared to be breathing fine. Staff informed the family member that the resident's hands were to too cold to get an oxygen saturation reading. There was not a sense of urgency when talking to the facility about his condition and he did not realize that going to the hospital was recommended. The facility was going to sit the resident up and call the family back in an hour. The family member stated he did not receive a call until the facility's nurse called to say the resident had passed away. On [DATE] at 08:54 AM, LN H stated she worked on [DATE], then was off duty until [DATE] for the 06:00 PM shift. LN H stated she did not notice any abnormal swelling on [DATE] and Consultant Physician Extender GG had seen R1 on [DATE]. LN H stated she was trying to see if R1's catheter situation had been addressed and low output was normal for him around 100-300 ml per shift. R1 would drink water during her shift and the CNA's would empty the catheter. The catheters were emptied as needed, but at least once a shift at the end of the shift. LN H stated she was getting report from LN G when one of the CNA's said R1 was not breathing, so her and LN G went to assess R1, and he lacked vital signs. LN G went to check his record while CPR was started by CMA S and EMS contacted. Compressions continued until EMS took over. LN H stated she was not aware of any difficulty with compressions because at that point she was at the desk and LN G was assisting. LN G called 911 and notified a family member. On [DATE] at 10:28 AM, Administrative Nurse E stated she recalled R1 having no urinary output and did not recall if the physician was notified or not. After checking documentation, Administrative Nurse E stated she did not notify the doctor and assumed the day shift would do so as she would not notify the physician in the middle of the night for that reason, and passed it on in report to LN G. Administrative Nurse E stated R1's output fluctuated between 300-600 ml but did not specify per shift or day, the charge nurse monitored output, and confirmed his output from 11/05-[DATE] was not appropriate with the increase in the torsemide on [DATE], and Consultant Physician Extender GG should have been notified. On [DATE] at 11:16 AM, Administrative Nurse D stated the nurses were responsible for monitoring urinary output and the CNA's emptied and reported the amount to the charge nurse. Administrative Nurse D stated she would expect the nurse to notify the physician if there was little or no urinary output present and would expect an increase in output with administration of Torsemide. Administrative Nurse D stated she was under the impression someone notified the physician of low urine output. Administrative Nurse D reported on [DATE], LN G was the charge nurse and at approximately 11:07 AM asked her to go look at R1 as he could not get R1's oxygen saturation, his hands were cold, he did not feel good, and R1 would not talk to LN G, so she went down to his room to assess him. R1 had on oxygen when she went to assess him, his lungs were clear, no shortness of breath, his hands were really cold, so she did warm packs and warm blankets on his hands and arms to try and warm them up. R1 would not talk to her, and she was not able to get a measurement of his oxygen saturation. Administrative Nurse D stated she contacted Consultant Physician Extender GG around noonish and was told he could be sent to ER if we needed to, but the whole time R1 did not want to go. Administrative Nurse D stated she went back around 01:20 PM and his hands and arms were cold and he refused to go to ER so she then called the family member who stated if R1 did not want to go do not make him, but try to raise the head of the bed to see if that helps, and did not believe when she talked to the family member she specifically said they had an order to send R1 to the ER. Administrative Nurse D stated she was not aware that R1 lacked urinary output and did not talk to the physician extender about urinary output, and stated she was in and out of the room that afternoon to check on R1 until she left, which was usually around 04:00 PM. Administrative Nurse D stated LN G should have checked his vital signs and would expect staff to document vital signs. On [DATE] at 01:14 PM, Consultant Physician Extender GG reported on her visit on [DATE], R1 had more swelling in his legs, so she increased the diuretic, and the staff had reported his edema was gradually increasing, and staff elevated his legs. Consultant Physician Extender GG stated she expected an increase in urinary output with the increase in the diuretic and should have been notified of lack of increase in the urine output and lack of urine output, as that was a problem. Consultant Physician Extender GG stated the facility should have made her aware of any urinary output less than 30 ml in an hour. Consultant Physician Extender GG stated she was not aware of R1's change of condition on [DATE]. If staff would have notified the physician extender, she would have given the order to send him to the ER. On [DATE] at 01:47 PM, CMA R stated CNAs emptied the catheters at least once on an eight-hour shift, and some nurses wanted the output documented in the electronic record and some wanted it on a piece of paper so they could see it and document the output themselves. CMA R stated staff should report to the nurse if there was lack of urine output or change in the urine color. On [DATE] at 02:51 PM CNA M reported she recalled on [DATE], R1 had 100 ml of urine output the whole shift. He liked tea, and she made him a big mug and he drank all of what was in the mug. On [DATE], she could feel fluid when rolling R1 and holding him over, it was leaving indentions where she would touch his leg and told the nurse. She reported the resident had the same edema on [DATE]. CNA M stated R1 was breathing okay on [DATE] and he would change the level of the head of the bed and liked it lower, but not flat. She did not notice any increase in his abdominal swelling however, his scrotum was swollen too, so she arranged the catheter tubing to see if that would improve urinary output and placed his legs on a pillow to elevate his legs. On [DATE] at 03:10 PM, CNA O stated on [DATE] she came in at 02:00 PM and when exiting another resident room, she glanced at R1 and noticed his head of bed was straight up and thought that was weird as he never liked to sit up straight. The resident had an oxygen concentrator in the room, which was new. CNA O offered him a drink as his mouth was really dry and R1 shook his head no. He was trying to talk and seemed like he was trying to catch his breath. The resident's nasal cannula was off, and staff placed the resident's oxygen nasal cannula back on him. CNA O stated she did not tell the nurse at that time as she felt the nurse was probably already aware since R1 had oxygen in place. CNA O stated his hand was cold and had noticed before that day his edema was real bad. CNA O stated when staff would roll R1 over and hold him, fingerprints would stay in his skin and be that way for quite some time to his legs and his back. CNA O stated on [DATE] or [DATE], he was hardly having any urinary output and it was a little bloody and she reported she notified the nurse. CNA O stated his output was around 100 ml, but he was still drinking the same amount as usual. On [DATE] at 04:14 PM, CMA S stated on [DATE], R1 took his morning medication, but not his afternoon ones, because he was very out of it that afternoon and had a hard time breathing. He was on oxygen. CMA S stated she prepared his afternoon medications, she was having a hard time understanding what he was saying, and his voice was raspy and stated this was not normal for him at all. CMA S stated she told LN G he was having a hard time breathing and then talked to Administrative Nurse D, and asked if anyone had been called as she did not think he was doing well and Administrative Nurse D told her she had called a family member and there was a little decline, and R1 did not want to go to the hospital so the family member said to respect his wishes and do not send him. CMA S stated that was probably around noon. CMA S stated she saw him again around 04:00 PM to 05:00 PM, and R1 was coherent and said thank you but could not get any other words out, and he did not take his medications at that time. CMA S stated while she was counting medications with the nurse, a staff member reported R1 was unresponsive. CMA S stated she started CPR and when she gave the first compression it sounded like water like he was completely full of fluid. CMA S stated she provided CPR until EMS arrived and took over. CMA S stated the week before she had emptied R1's catheter and his urine had been cloudy and thick, like sediment and pus and stated she had reported that to the charge nurse. The facility's policy for Edema dated [DATE], revealed the current primary care provider would be notified immediately of any shortness of breath, difficulty breathing, or chest pain as these can be signs of pulmonary edema, which requires prompt treatment. The staff were to notify the primary care provider of any new or worsening signs and symptoms of edema and follow recommendations. The facility policy PCP (primary care physician) Notification of Change dated [DATE] included to observe and report significant change in condition and included to monitor resident's condition frequently until stable. The facility failed to conduct a thorough assessment of R1 with a change in condition. The facility failed to notify the physician when R1 did not have an increase in urinary output following an increase in physician ordered diuretic medication on [DATE]. The facility failed to notify the physician on [DATE] when the resident lacked urinary output for greater than 24 hour and complained of difficulty breathing. On [DATE] the facility further failed to provide ongoing assessments of R1 by a licensed nurse after the resident had complaints of difficulty breathing, and inability to obtain oxygen saturation level, when the resident had coolness of his hands and arms after application of a warm blanket, and after application of oxygen for over four hours from 01:15 PM to approximately 05:52 PM. The facility provided CPR when staff found the resident unresponsive until medical emergency services (EMS) arrived. The resident died on [DATE] at 06:38 PM. The lack of ongoing assessments and monitoring placed all residents in the facility in immediate jeopardy. On [DATE] at 01:55 PM, Administrative Staff A was informed the residents were in immediate jeopardy and was provided the Immediate Jeopardy Template for failure to conduct a thorough assessment with a change in condition, failure to notify physician with little and lack of output following an increase in diuretic medication, and failure to provide further ongoing assessments of R1 after his complaint of difficulty breathing and inability to measure his oxygen saturation level. The facility removed the immediate jeopardy on [DATE] at 06:30 PM when they completed the following: 1. The physician and/or nurse practitioner or physician's assistant will be notified of significant changes in a resident's condition. If after hours, call their cell phone. If no answer, call the hospital and ask the operator to page the physician and/or nurse practitioner or physician's assistant or the alternate physician that is taking call for the resident's primary care provider. 2. If a resident experiences any significant change and they are not on Hospice Palliative Care, or skilled End of Life, the resident will be automatically sent to the ER. admission packet will be modified for new admissions to state that fact. All current residents will receive and sign an addendum to the admission Agreement. 3. All staff will be in-serviced and trained on the change of practice. Immediate in-service will start on [DATE] and be completed on [DATE]. Completion of staff in-service was [DATE] at 06:30 PM 4. The daily skilled charting observation form in Matrix had been updated to include change of condition charting, which includes the mandatory inclusion of vital signs, PCP notification, and urinary output. This will go into effect immediately and will include any skilled resident or any resident that has had a change in condition. 5. A focused QAPI meeting addressing the finding was held with Administrator, Director of Nursing and Medical Director in attendance on [DATE] The facility provided an acceptable plan for removal of the immediate jeopardy on [DATE] at 06:00 PM. the survey team validated the immediate jeopardy was removed on [DATE] at 06:30 PM following the facility's implementation of the plan for removal of the immediate jeopardy. This deficient practice remained at a scope and severity of J (a situation in which immediate corrective action is necessary because of the likeliness to cause serious injury, harm, impairment, or death) and was lowered to a scope and severity of G (isolated with actual harm) following the removal of the immediate jeopardy.