**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00153179. Based on interview and record reviews the facility failed to adequately assess/monitor a resident with an identified change of condition, notify the Physician of continued decline and transfer the resident to a higher level of care in a timely manner, for one of six residents reviewed for a change in condition, resulting in an approximately 12 hour delay in identifying and treating the resident for an acute stroke contributing to the resident's death. The deficient practice resulted in the increased likelihood of serious harm, serious injury and/or death to occur. Findings include: The Immediate Jeopardy (IJ) began on [DATE] when the facility staff failed to adequately assess/monitor R802 who had an identified change of condition and notify the Physician of the continued decline. The IJ was identified on [DATE] and the Administrator was notified of the Immediate Jeopardy on [DATE] at 4:08 PM. A plan of removal was requested at that time to remove the immediacy. The surveyor team confirmed by Observation, Interview and Record review that the Immediate Jeopardy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal. The noncompliance remains at an isolated event with the potential for more then minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA). A review of a complaint submitted to the SA documented allegations of the facility's failure to timely address a change in condition and the delayed transfer to the hospital for R802 that resulted in death . An Emergency Documentation ED Triage report dated [DATE] at 7:40 AM, documented in part . pt (patient) to ed (emergency department) via EMS (emergency medical services) pt was found unresponsive low 02 (oxygen level) upon arrival pt AOx0 (alert and oriented times zero) . Transferred From: Skilled nursing facility . Glasgow coma Scale (measures the extent of impaired consciousness and severity of brain injury)- Eye Opening Response Glasgow: To pain . Best Verbal Response Glasgow: None . Best Motor Response Glasgow: Flaccid . Glasgow Coma Score: 4 (indicates a severe level of impaired consciousness and suggests serious neurological impairment) . Temperature Rectal . 100.0 . Pulse Rate: 114 . Respiratory Rate: 24 . Systolic Blood Pressure 170 . Diastolic Blood Pressure 93 . Oxygen Saturation: 84% . Oxygen Therapy: Non rebreather . Tracking Acuity: 1 - Immediate . Diagnosis . unresponsive . Level of Consciousness . unresponsive . intubated . A review of the medical record revealed R802 was admitted to the facility on [DATE], with the primary diagnosis of aftercare following joint replacement surgery. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R802 was mostly Independent with some limited assistance needed for Activities of Daily Living (ADLs). The resident was their own responsible party and signed to be a Full Code status. An Admission nursing assessment dated [DATE], documented R802 to be oriented to person, place, time, situation and noted to be verbally appropriate. Further review of the assessment documented breath sounds to be clear and heart sounds to be regular. The assessment documented the admission vitals as follows: Temperature 97.6. Pulse 94, Respirations 18 and Blood Pressure 125/75. A review of the complaint submitted to the SA documented on [DATE], . the resident was throwing up non-stop. The complainant states the resident had to use a garbage can to throw up in because staff weren't around to give him an appropriate container . A review of the medical record and progress notes, revealed no documentation of R802's emesis episodes, however a Zofran 4 MG (milligram) tablet was ordered on [DATE]. The order noted . Give 1 tablet by mouth one time only for Nausea and Vomiting for 1 Day Nausea and Vomiting . A review of the [DATE] Medication Administration Record (MAR) documented the Zofran medication to have been administered on [DATE] at 1:36 PM. A review of the blood pressure summary documented on [DATE] at 8:30 AM, R802's blood pressure was 167/101 mmHg (millimeters of mercury). A review of the medical record revealed no progress notes on [DATE], however a Physician order for hydralazine HCl 25 mg tablet was ordered on [DATE], that noted . one time only for elevated bp (blood pressure) for 1 Day . This medication was documented as administered on [DATE] at 6:26 PM. A review of the Blood Pressure Summary documented the following on [DATE]: At 9:55 AM- 177/109 mmHg At 10:04 AM- 172/106 mmHg At 10:30 AM- 167/101 mmHg A review of the [DATE] MAR documented Metoprolol Tartrate 50 mg by mouth one time only for HTN (hypertension- high blood pressure) for 1 Day. This medication was documented as administered on [DATE] at 10:16 AM. A review of the progress notes revealed the following: On [DATE] at 11:42 AM, a Physician Assistant (PA)- later identified as PA D note documented in part . Reason for visit . Request by patient/family/nurse regarding cough, Urianry <sic> sx (symptoms) . Patient seen and examined. Resting comfably <sic> in bed. Awake, alert, in no acute distress. No <sic> as respisnvei <sic> to answering questions as usual. Afebrile, non-toxic. C/o (complaints of) cough. Not eating or drinking much per nurse. Pt (patient) had N/V (nausea/vomiting) over the weekend- resoled <sic>. BP elevated over the weekend and this AM (morning). Received hydralazine over the weekend. Per nurse, pt requesting melatonin to be discontinue due to nausea from it. Also, C/o dysuria (painful urination), urgency, urianru <sic> frequency. +generalized weakness. C/O pain, worse with movement and better with rest and meds (medications). Denies fevers, chills. Denies CP, SOB (shortness of breath) , N/V, abd (abdominal) pain. Tolerating PT (physical therapy)/OT (occupational therapy) . Physical Exam BP 169/99 P (pulse) 99 R (respirations) 22 T (temperature) 98.6 02 (oxygen saturation) 90% . chronically ill appearing, appears weak . PERRLA (pupils equal, round, reactive to light and accommodation), EOMI (extraocular movements intact), MMM (moist mucous membranes), + HOH (hard of hearing), CV (cardiovascular): RRR (regular rate and rhythm), S1 S2 (first and second heart sounds), Resp (respiratory): CTAB (clear to auscultation bilaterally), no wheezes, no rales . Alert, awake, some confusion, appropriate mood and affect. Assessment N/V- resolved, Urianry <sic> sx, Dehydration, HTN (hypertension) Insomnia, S/P (status post) fall Left femoral neck fracture s/p anterior THA (total hip arthroplasty) . DVT (deep vein thrombosis) ppx (prophylactically) per ortho (orthopedics) . Plan . Dehydration: check CBC (complete blood count) BMP (basic metabolic disorder) stat (immediately). Begin IV (intravenous) fluids as patient not eating/drinking much today per nurse. Cough: Check labs, check CXR (chest x-ray) and covid. Urianry <sic> sx: check labs, check UA (urinalysis) C&S (culture & sensitivity). HTN: Metoprolol 50mg x1 this AM with improvement. Pt (patient) not on meds. Monitor for persistent elevations . d/w (discussed with) patient at length and pt verbalized an understanding of all risks and instructions. All questions answered. Pt verbalized an understanding of all instructions. D/W staff at length . A Nursing note dated [DATE] at 1:25 PM, documented in part . The Change in Condition/s reported . Altered mental status . Guest is less responsive than baseline. Not eating or drinking. Irregular movement of arms. High BP (blood pressure)/ P (pulse) . Primary Care Provider responded with the following feedback . stat labs, stat CXR, IV (intravenous) fluids . Blood Tests Urinalysis or culture X-ray . New Intervention Orders: IV or subcutaneous fluids . This note was documented by Licensed Practical Nurse (LPN) A. A Physician note dated [DATE] at 10:49 PM, documented in part . labs reviewed- leukocytosis (elevated white blood cell count) noted. Pt with Urianry <sic> sx and dark, cloudy urine per nurse. Will begin IV Rocephin (antibiotic) 1 gm (gram) QD (every day) x7 days- 1sr <sic> dose today . Further review of the complaint submitted to the SA and interviews conducted with the complainant noted that on [DATE] the family visited the resident and found them . laying in bed with his tongue hanging out of his mouth and his breathing was shallow . female nurse on the afternoon shift told (the family) the resident was getting a Covid test and could possibly have pneumonia because he hadn't been responsive and was unable to be woken from his sleep . A review of the [DATE] MAR revealed the following medications were not administered on [DATE] for the HS (hour of sleep) doses: Apixaban 2.5 mg for DVT (deep vein thrombosis/blood clot) prophylaxis, Aspirin 81 mg for DVT prophylaxis, Calcium Carbonate 500 mg, Metformin 500 mg, Senna-Docusate Sodium 8.6-50mg, and Sodium Chloride solution 0.9% intravenously for dehydration. There was no documentation in the medical record of the Physician to have been notified of the omitted medications. A Nursing note dated [DATE] at 6:54 AM, documented . Chest x-ray reviewed, unremarkable. Resident has remain in the same condition throughout the shift. Resident is stable, yet unarousable . This note was documented by LPN B who worked the midnight shift on [DATE] from 7:00 PM on [DATE] to 7:00 Am on [DATE]. Review of the medical record revealed no documentation of any additional assessment of the resident on the midnight shift despite LPN B to have documented that the resident remained unarousable all shift. A review of a facility policy titled Acute Condition Changes revised [DATE], documented in part . Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician . Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status . The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response . A review of the medical record revealed on [DATE] at 9:24 PM, R802's vital signs were documented as: BP 169/99 mmHg, Temperature 98.6, Pulse 99, Respirations 22, and 02 Sats 90% on room air. (Note this is the same vitals documented in the Physician Assistant - PA D note from 11:42 AM on [DATE]. The medical record revealed no adequate monitoring of the resident from [DATE] at 9:24 PM to [DATE] at 7:14 AM. On [DATE] at 7:14 AM a pulse was noted at 115 beats per minute. At 7:15 AM R802's temperature was noted as 100.5 F (Fahrenheit) and 02 Sat was noted at 79% on room air (normal readings would be 90% or above). There was no documentation of a blood pressure obtained at this time. A review of a Nursing note dated [DATE] at 7:22 AM, documented . Per provider, resident is being sent out to hospital 911 . This note was documented by LPN B. A review of the hospital records revealed the following: A History & Physical dated [DATE], documented in part . comes to the emergency room with acute hypoxic respiratory failure, sepsis secondary to UTI (urinary tract infection), acute toxic encephalopathy. He has been also intubated. Right now, he is in ICU (intensive care unit). Management per ICU team . An Admit/Progress Note dated [DATE], documented in part . ICU team at bedside to round at 0900. Patient is off sedation, does not follow commands. Pending CT (computerized tomography scan) Head . seen and examined . breathing over vent, withdrawing to pain but no response to commands pupils equal but non reactive . The patient does have cerebral edema (swelling of the brain) (Addendum [DATE]) . A Neurosurgery Consultation note dated [DATE], documented in part . Patient . with recent history of left hip fracture s/p (status post) THA (total hip arthroplasty) on [DATE], reportedly on Eliquis for DVT prophylaxis who presented to hospital from rehab facility on [DATE] . Patient was discharged to rehab facility in good condition was awake alert and oriented and answering questions appropriately. At some point on . [DATE], patient became unresponsive not answering questions. For unknown reasons, patient was not brought to the ER (emergency room) for evaluation until the morning of [DATE]. This morning ([DATE]) CT head was obtained which demonstrated bilateral cerebellar infarcts (stroke) with mass effect on the fourth ventricle and obstructive hydrocephalus (the flow of cerebrospinal fluid is blocked along one or more passages connecting the ventricles). Neurosurgery was consulted in this regard. At the time of evaluation, patient intubated off sedation. Does not open eyes pupils 4 mm (millimeters) nonreactive, absent cough/gag/oculocephalic (neurological test used to assess the brainstem function) reflexes . Recommendations: Long discussion was had with patient's brother and sister at bedside. CT findings and patient's clinical status and neuroexam were described in depth to family. We explained that given his poor neurological exam, his prognosis is extremely guarded and his likelihood of functional recovery is quite low. He has likely suffered some irreversible damage to his brain/brainstem based on neuroexam . Ultimately given the patient's poor prognosis, his brother and sister agreed that patient would not want to undergo surgery and elected for comfort measures . Review of a Discharge Documentation dated [DATE], noted the resident was pronounced deceased at 2:01 AM. A review of the Certificate of Death documented the only cause of death noted as . Acute Stroke . Approximate Interval Between Onset and Death four to five Days . On [DATE] at 12:16 PM, LPN B was interviewed via telephone and was asked where they document the residents vitals that are obtained, LPN B replied they document it in the (Electronic Medical Record) chart. LPN B was asked about the vitals not being obtained for R802 on the nightshift of [DATE] into [DATE]. LPN B stated they were unsure why there was no vitals documented. LPN B could not recall the values obtained. LPN B then stated in part . It was alarming to me (R802's presentation/status). I had been off two or three days. Dayshift said he (R802) was already like that (unresponsive) and the Physician had been notified. Based on what I was told we were not able to send him (R802) to the hospital . When asked why they were not allowed to send R802 to the hospital, LPN B replied that the dayshift nurse (LPN A) had informed them of that in their verbal shift report at the change of shift. LPN B then stated in part . The same thing the unit manager (Unit Manager- UM, later identified as UM G) told me as well and I blew up on him. I tried advocating for him (R802) throughout the night . When asked who they contacted in attempts to advocate for R802, LPN B stated the provider that was on call, they were unsure of who it was. LPN B stated in part . I told him (UM G) No, you need to come and look at him and he needs to go to the hospital. I was pissed off the entire night and I begged them to send him and they told me I cannot . LPN B was asked why R802's medications had not been administered for the evening of [DATE] and stated in part . No, he couldn't take nothing. He (previously) was A&O x4 (alert and oriented times four) which is why I was so upset. He would get up on his own and do his own personal care. He would talk to me (in the past), but he couldn't do any of that when I came on shift. He was not responding to me at all. When I went in there (R802's room) I was shocked that they would not let me send him to the hospital. It was upsetting they would not allow me to send him to the hospital. The IV and antibiotics was not enough for me, but they would not allow us to send him out. I had to wait until the morning to talk to (UM G name). I blew up on him. I went off and told (UM G) it was unsafe and this is my license and he (R802) needed to go to the hospital . It was very disheartening because I wanted to send him out when I got to work (at the beginning of their shift) but they told me that I could not . LPN B then stated . Please talk to (LPN A name) first because they (Administration team) have a habit of trying to cover their stuff up. (LPN A) was upset too because they wouldn't let her send him out before on dayshift . When asked who is they that they keep referring to, LPN B kept referencing the report given to them by LPN A of not being able to send the resident to the hospital. On [DATE] at 12:31 PM, a message was left on LPN A voicemail to return the call. On [DATE] at 1:05 PM, an interview was conducted with UM G. When asked how often a resident with an identified change of condition should be assessed and monitored, UM G replied in part . it depends on the change of condition, very frequently the nurse should be spending a lot of time with that patient if they were responsive and now unresponsive. At least hourly . UM G was then asked about R802 and UM G stated they remembered the resident had a change from their baseline and the Nurse and PA was in there (R802's room). UM G stated they didn't have a chance to see the resident that day. UM G stated they were approached by the Nurse the next day who said (R802) was not doing well and they did not like the way that (R802) was presenting. UM G stated . I told the PA he didn't look good and ensured I had a fresh set of vitals . UM G stated they were instructed to send R802 to the hospital. On [DATE] at 1:18 PM, a message was left on PA D's voicemail to return the call. At 1:24 PM, a text message was sent to the Medical Doctor (MD) C who was the Physician assigned to R802. A reply was not received that day. At 1:37 PM, LPN A returned the surveyor's call. When asked about R802 on the day of [DATE], LPN A replied when they came on duty R802's blood pressure was way up. LPN A stated they called to get an order for something and kept checking on R802 because . he was not responding normally . LPN A stated R802 was very hard of hearing and had speaker things that they would utilize. LPN A stated R802 was not eating and . he wasn't very responsive . LPN A stated R802 would respond by groaning but . he was getting worse responsive wise . LPN A stated they notified (PA D) and the PA ordered a few things. LPN A stated they then talked to UM G (their supervisor) who was sitting with (Unit Nurse Manager- UNM J) and . they would not get off their butts and I was pissed . LPN A stated they talked to R802's brother and stated they really thought R802 needed to go to the hospital. LPN A stated . (UM G name) told me no, you already have orders for him (R802) . LPN A stated I told (UM G name) to go down there and look at (R802) and LPN A stated UM G told them they were busy. LPN A stated . I was so scared . I was like please come and look at him and set eyes on him all the CNAs (Certified Nursing Assistants) said this is not him (R802's presentation) . The Nurse (LPN B) sent him out because she had enough . LPN A then stated in part . I am an LPN but I have been doing this for a million years and I asked (UM G name) to come and see him and he wouldn't. It was not a good situation and the managers put a stop to it and wouldn't allow us to send him out. I was pissed about it. This has happened before, there have been other incidents. There is a lot of things that they do there, they don't let us chart the truth . It was disturbing and the fact that we got no support and I couldn't do what I wanted to do and send him to the hospital because I had no manager support . Despite to have verbalized that R802 needed to go to the hospital, neither LPN A or LPN B called emergency services timely. At 1:58 PM, PA D returned the surveyor's call. When asked if they were notified of the change in condition of the resident becoming unresponsive, PA D stated in part . I was notified in the morning and prior to leaving the shift he (R802) was stable. He was able to talk to me when I assessed him and I ordered labs and he was awake and alert. No, I wasn't aware until they reported to me the next morning . On [DATE] at 3:35 PM, the Administrator and Director of Nursing (DON) was interviewed and asked if they were familiar with R802. The DON stated they believed he came to the facility after he had a fall. The DON remembered the resident was hard of hearing and had a headset that looked like a Walkman (assisted him with hearing). The DON stated they remember the resident would always come down to the community room to eat. The DON stated they remember the resident told them their story (on what happened that caused them to be at the facility) but they couldn't remember it. At this time the Administrator and DON were both interviewed on the concerns of the facility staff inadequately assessing/monitoring a resident with an identified change of condition, the failure to notify the Physician of continued decline and the delay in transferring the resident to a higher level of care, both acknowledged the concerns and offered no additional explanation at that time. At 5:57 PM, a second phone call was received from LPN A who stated the facility Administration team were repeatedly calling them. LPN A stated . They told me that I couldn't tell the nurse (LPN B) not to call the doctor for the resident with a change in condition. I told them I didn't tell the nurse (LPN B) not to . They kept trying to blame me and I hung up on them . On [DATE] at 9:07 AM, the [NAME] President of Operations (VPO) H, Medical Doctor (MD) C and Regional Nurse Consultant (RNC) I requested to provide additional information. MD C reported they had information that they felt would be useful for the investigation. MD C went on to verbalize that they talked to their PA (PA D) who had examined R802 on [DATE] and the resident didn't have any signs/symptoms of a stroke. MD C stated the stroke was identified the day after the resident went into the hospital and the resident was moving his limbs in the ER. MD C stated the resident was on a blood thinner and aspirin and they don't believe that they could have change the direction of how the incident played out. The findings of inadequate assessment/monitoring, lack of notification to the Physician of the continued decline and the delay in transferring the resident to the hospital was discussed. MD C was asked if they were notified by the nursing staff of the continued decline of R802 and MD C stated they were not notified. RNC I stated the medical team was not aware of a continued decline and believed there was a glitch in the facility's EMR as to the reason a blood pressure was not documented on the morning of [DATE]. It was discussed with VPO H, MD C and RNC I that if they had any additional information they could provide it for further review. On [DATE] at approximately 10:00 AM, UM G and the DON was recalled together for a second interview. UM G was asked about being informed multiple times by the nursing staff of the concern of R802'si ws condition declining, the request for them to set eyes on R802 and to send R802 to the hospital. UM G replied they recalled being asked about the patient and informing the nurse that if it was any change of condition with the resident to notify the provider. When asked if they told the nursing staff that R802 was not going to the hospital, UM G stated they did not say that (R802) was not going to the hospital and remembered telling the staff to contact the provider for changes. UM G was asked to recall [DATE] the morning R802 was transferred to the hospital. UM G stated the nurse said (R802) wasn't presenting well. UM G stated they remember going into the room with the nurse and they could not recall who obtained the vitals that morning, but they remembered they called PA D who instructed the resident to be sent out. UM G stated they remember the resident only responded to painful stimuli. When asked what was different about R802 from the evaluation completed the day before by PA D and (R802) not presenting well on the morning of [DATE], if there was no alleged changes for R802 throughout the night and UM G stated in part . with the new vitals that we just obtained which is the new change of condition and we sent him out . The DON was asked if they felt it was acceptable practice for a resident to have an identified change of condition and not be closely monitored or have vitals obtained from [DATE] at 9:24 PM until [DATE] at 7:14 AM, especially considering the one time doses of blood pressure medications that were given in attempts to control R802's blood pressure. The DON replied . I expect them to follow the physician orders . The DON was asked if there needed to be an order for the nurse to monitor and obtain the vitals of a resident with an identified change of condition and the DON repeated that they expected the nurses to follow the Physician orders. On [DATE] at 11:30 AM, RNC I entered into the conference room and stated that Unit Nurse Manager (UNM) J seen R802 on [DATE]. Shortly after UNM J entered the conference room and stated LPN A was believed to be irritated with their assignment on [DATE] because they were normally assigned to another part of the facility. UNM J stated they remember (R802)'s vitals to be fine and beautiful. UNM J stated they remembered that R802 was responsive when they saw them just slow to respond. UNM J stated they were in the room with LPN A. When asked where their documentation was of their assessment from R802, UNM J stated they did not document the assessment. UNM J was asked what time they went off duty on [DATE] and stated they leave the facility by 4 or 4:30 PM. On [DATE] at 10:14 AM, a voicemail was left on the surveyors phone from LPN A which noted in part, . He (R802) would move you know moan and and <sic> and kind of push away . he (R802) wasn't unresponsive on my shift. He responded to movement to. He would mumble and try and talk . he was the same . he didn't get worse on my shift . No additional information was provided to the survey team before the end of the survey. The Immediate Jeopardy that began on [DATE] was removed on [DATE] wen the facility took the following actions to remove the immediacy, including the following: Resident 802 no longer resides at the facility. Root cause: The physician was not notified by LPN A and LPN B of the resident's continued decline (unresponsive, not alert, not responding, and unable to take medications), leading to the resident being transferred to the hospital. A one-time audit was completed for the last 14 days of nurses notes and change of conditions to ensure appropriate MD notification and follow-up was completed. There are no concerns noted. Licensed Nurses were re-educated on [DATE] on the change of condition policy, including appropriate assessment, and timely notification of the physician to prevent serious injury, harm, and or death. SYSTEM CHANGE: The facility nurse leadership team did a one-time visual assessment of all current residents to ensure no change in condition is noted and required physician notification is completed timely. No concerns were noted. The policy on change in condition was reviewed and deemed appropriate. DON/designee will review 5 charts weekly x 12 weeks to ensure appropriate MD notification and change of conditions have been completed timely. Non- compliance will be addressed immediately. Audits will be forwarded to QAPI (Quality Assurance Process Improvement) committee for review and recommendations. COMPLIANCE DATE: [DATE]