**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family, staff, Nurse Practitioner (NP), Physician's Assistant (PA), and physician (MD) interviews, the facility failed to communicate with Resident #1's Medical Provider about intermittent loose stools following an order for polyethylene glycol (a medication used to treat occasional constipation and soften stool) with a history of Clostridium difficile (a bacterial infection in the colon which have symptoms that range from diarrhea to life-threatening damage to the colon), also known as C-difficile. The facility failed to notify the medical provider of an abnormal stool culture for a resident with C-difficile. The facility failed to notify the medical provider of acute changes in condition consisting of multiple loose stools, increased confusion, disorientation, and new behavior of attempting to climb out of bed on 11/6/23, and low blood pressure that were not at her baseline. Resident #1 was sent to the emergency room and was diagnosed with sepsis (a life-threatening complication of a current infection), hypothermia, and type 2 myocardial infarction (heart attack). Resident #1 expired on 11/10/23. This deficient practice affected 1 of 2 residents reviewed for physician notification. The immediate jeopardy began on 11/7/23 when Resident #1's physician was not notified of acute changes in the resident's condition. The immediate jeopardy was removed on 11/23/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D no actual harm to ensure the completion of education and monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included status post cystitis without hematuria (bladder inflammation without blood present in the urine) and surgical intervention of calculus of the bile duct with chronic cholecystitis without obstruction (gallstones) and abdominal hernia without obstruction or gangrene and a history of C-Difficile colitis. A hospital Discharge summary dated [DATE] indicated Resident #1 presented to the emergency room (ER) with abdominal pain and vomiting which required abdominal surgery for the gallstones. A physician's order dated 10/5/23 indicated Amoxicillin/Clavulanate 500-125 milligrams (mg) (antibiotic used to treat infection) three times per day for 3 days for cystitis. Additionally, Lisinopril (ace-inhibitor used to treat heart failure and blood pressure)10mg daily by mouth was ordered for hypertension. A one-day post admission progress note dated 10/6/23 written by the NP indicated Resident #1 was admitted to the facility after being hospitalized from [DATE] through 10/5/23 status post endoscopic retrograde cholangiopancreatography (a procedure using a scope to diagnose and treat problems of the biliary or pancreatic system) on 9/28/23 and cholecystitis with choledocholithiasis (gallstones), incarcerated hiatal hernia (part of intestine trapped in the sac of a hernia which can become life threatening if untreated) on 10/3/23. The note indicated Resident #1 was to receive Amoxicillin/ Clavulanate 500-125 mg by mouth three times per day from 10/6/23 through 10/9/23. The note also indicated she was positive for constipation as she was pushing and straining to have a bowel movement last night (10/5/23) with her abdomen soft, non-tender, and without hepatospleenomegaly (liver and spleen enlargement). The note also revealed Resident #1 had hospital labs on 10/4/23 which indicated the following values: slightly elevated white blood cells (WBC) 12.07 and a normal creatinine (test used to monitor kidney function) level of 0.9. The assessment listed the following: negative for behaviors, no gastrointestinal (GI) upset with ability to tolerate foods and liquids, and hypertension with systolic blood pressures ranging between 120's to 140's on treatment of Lisinopril daily and monitor blood pressure daily. A physician's order dated 10/7/23 indicated Loperamide 2 mg (medication used to treat loose stools) tablet after each loose stool as needed for diarrhea x 1 day. A review of the nurses' progress notes for 10/07/23 revealed nothing related to loose stools or contacting the Medical Provider to obtain an order for Loperamide. A review of the Medication Administration Record (MAR) dated October 2023 revealed Nurse #6 administered Resident #1 a single dose of Loperamide on 10/7/23. Attempts to contact Nurse #6 were unsuccessful. A skilled progress note written by Nurse #7 dated 10/8/23 at 4:23 PM indicated Resident #1 complained of loose stool after lunch. The note did not indicate Nurse #7 notified the Medical Provider of Resident #1's loose stools. A review of the MAR dated October 2023 indicated Nurse #7 administered Resident #1 a single dose of Loperamide on 10/8/23. An interview on 11/28/23 at 10:00 AM with Nurse #7 revealed she could not recall Resident #1 as she was moved to the South Unit shortly after admission and Nurse #7 had no further involvement with her care. She could not recall notifying the Medical Provider of the loose stools. A review of the Medication Administration Record (MAR) dated October 2023 indicated Resident #1 received Loperamide 2mg on 10/7/23 at 10:29 AM and again on 10/8/23 at 5:14 PM. A provider progress note was written by the NP on 10/9/23 indicated Resident #1 was seen for a 3-day post admission visit. The note indicated Resident #1 was not feeling well and had complained to her (the NP) that she began to experience loose stools over the weekend, and she had already experienced 3 diarrhea/ water stools that day prior to the visit. Resident #1 complained of abdominal pain but no nausea or vomiting. Resident #1 felt bloated with indigestion. The note indicated Resident #1 had reported to the NP about her history of C-Difficile on 2/20/23. The note further indicated orders were provided to obtain a stool specimen to test for C-Difficile and discontinue Loperamide that was administered over the weekend. A physician order dated 10/9/23 indicated obtain stool specimen to test for C-Difficile. A laboratory report dated 10/10/23 indicated Resident #1 was positive for C -difficile colitis. A progress note written by the NP on 10/11/23 for a 5-day post admission visit. The note indicated Resident #1 continued to complain of diarrhea, abdominal pain, and indigestion. C-Difficile culture continued to be pending at the time of the visit. Resident #1 is currently not able to eat well, continued to have a soft, non-tender abdomen with hyperactive bowel sounds and negative for bladder distention. The note indicated Resident #1 had experienced 6 watery stools that day prior to the visit. The note further indicated new orders were received to start Cholestyramine 1 packet by mouth daily (used off label for bile acid diarrhea) and continue to monitor Resident #1's condition pending C-Difficile laboratory results. The note further indicated Resident #1 had blood pressure of 136/66 and to continue the Lisinopril as ordered. A nurse progress note written by the Unit Manager dated 10/11/23 indicated she spoke with the family member regarding Resident #1's abnormal lab results and testing positive for C-Difficile colitis and antibiotic therapy would be initiated. A physician's order dated 10/11/23 indicated Cholestyramine Light Oral Packet 4 grams (GM) give one packet by mouth one time a day related to diarrhea. A physician's order dated 10/11/23 indicated Vancomycin (antibiotic) 125 milligrams give one tablet four times a day for C-difficile. The order was discontinued on 10/12/23. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact. An admission History and Physical (H&P) written by the MD dated 10/12/23 indicated Resident #1 was positive for diarrhea, negative for confusion, and negative for dysuria or bladder distension. It also revealed Resident #1's abdomen was soft, non-tender, and no guarding or rebound present with normal cognition with good memory recall both recent and remote. The note stated Resident #1 had a laboratory test on 10/10/23 which was positive for C-Difficile. A laboratory report dated 10/12/23 indicated Resident #1's white blood cell (test to determine immune ability to fight infection) count was elevated to 26.7 (normal being 4.1 to 10.9), Creatinine (test for kidney function) was normal at 1.16 (normal being 0.5 to 1.20) and C-reactive protein was 28.70 (test for inflammation in the body- normal being less than 0.50). This report indicated it was reviewed by the Nurse Practitioner on 10/13/23 at 10:31 AM. A provider progress note written by the NP dated 10/13/23 indicated Resident #1 had been placed on quarantine for C-Difficile and continued to have watery stools, abdominal pain, and now nausea was present. Laboratory results were reviewed with the following noted: elevated WBC of 26.7, low calcium at 8, elevated BUN 21.1, normal creatinine at 1.16, low sodium at 132, and a high CRP of 28.7. At this visit, Resident #1 was positive for weakness and fatigue, decrease strength and mobility, and negative for confusion or bladder distension. Resident #1's plan of care listed included the following: Start intravenous (IV) fluids (Normal Saline 60 cubic centimeters (cc) per hour for 48 hours) secondary to a low sodium level. Repeat CBC and CMP on Monday (10/16/23) to compare trends. Resident was previously prescribed Vancomycin orally, but secondary to high WBC she was switched to Flagyl 500mg IV every 6 hours x 7 days. Discontinue Vancomycin once Flagyl had started. At this visit, Resident #1's blood pressures were reviewed to be between 120's and 140's systolic and staff were to administer Lisinopril as ordered. A physician's order dated 10/13/23 indicated Sodium Chloride 0.45% intravenous. Give 60 (ml) milliliters per hour for 3 days for dehydration, acute kidney injury and C-Difficile. The order was discontinued on 10/16/23. A physician's order dated 10/13/23 indicated Flagyl (antibiotic) 500 mg per 100 (ml). Provide 500 mg (IV) intravenously every six hours for Enterocolitis (fecal bacteria) due to C-difficile for 7 days. A laboratory report dated 10/16/23 indicated Resident #1's white blood cell count was normal at 9.0, C-reactive protein remained elevated at 15.8 and Creatinine was normal at 0.90. These lab reports indicated they were reviewed by both the PA and NP on 10/17/23 at 9:47 AM and 8:37 PM. A provider progress note written by the NP dated 10/16/23 indicated Resident #1 was seen for a 14-day post admission visit. The note indicated during this visit Resident #1 remained on IV fluids which completed 10/16/23 and Flagyl via midline IV and reported the diarrhea was uncontrollable. A review of the laboratory results dated [DATE] listed the following values: white blood cell count was normal at 9.0, C-reactive protein (a protein produced by the liver) remained elevated at 15.8 and Creatinine was normal at 0.90. The plan of care included the following: Continue Flagyl until completed and addressed a significant improvement in Resident #1's laboratory results with a normal WBC and improving BUN, Creatinine, and sodium levels. The note also indicated Resident #1's blood pressure remained between 120's and 140's systolic and continued on Lisinopril for treatment. No new orders were given on this visit. A provider progress note written by the NP dated 10/20/23 indicated Resident #1 had a slight improvement but continued to have diarrhea with staff reports of decrease odorous stools. New orders included: extend the Flagyl IV for a total of 10 days. A physician's order dated 10/20/23 indicated Flagyl (antibiotic) 500 mg per 100 milliliters (ML). Provide 500 mg (IV) intravenously every six hours for Enterocolitis due to C-difficile for an additional 3 days. A physician's order dated 10/24/23 indicated Flagyl 500 mg by mouth twice daily for C-difficile. The order was discontinued on 10/25/23. A surgeon's consultation form dated 10/25/23 indicated Resident #1 was seen for a follow up with constipation and new orders were given for polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation. A nurse progress note written by Nurse #4 dated 10/25/23 indicated Resident #1 was seen for a surgical consult and new orders to advance diet and give polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation. The note did not indicate Nurse #4 notified the Medical Provider of the new order or ongoing loose stools following antibiotic therapy. An interview with Nurse #4 on 11/28/23 at 9:00 AM revealed she could not recall the order provided by the surgical consult but entered as previously educated from the surgical consultation communication form. Nurse #4 did not question the order because the antibiotic treatment for C-Difficile was completed. Nurse #4 also could not recall if she notified the Medical Provider of the new order or that Resident #1 continued to have loose stools following antibiotic therapy. A physician's order dated 10/25/23 indicated polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation. A provider note written by the NP dated 10/27/23 indicated Resident #1 was seen for a 21-day post admission visit. The noted reflected Resident #1 had improved with GI symptoms but continued with on and off diarrhea mixed with some semi-formed stools. The note indicated Resident #1's had completed her IV antibiotics. The note also indicated Resident #1's blood pressure remained between 120's and 140's systolic and continued Lisinopril for treatment. No new orders were given on this visit. A review of the Medication Administration Record (MAR) dated October 2023 indicated Resident #1 received the following: - Amoxicillin/Clavulanate 500-125 mg one tablet every 8 hours for 3 days (10/6/23 through 10/8/23 for a total 8 doses) - Lisinopril 10 mg daily (10/6/23 through 10/31/23 except 10/20/23, 10/21/23, and 10/22/23 because BP was outside of the parameters) - Cholestyramine Light Oral Packet 4 GM give one packet by mouth one time a day related to diarrhea (10/12 through 10/31) - Vancomycin 125 milligrams give one tablet. Four times a day for C difficile (10/12 and 10/13) - Sodium chloride intravenous solution 0.4%. Used 60 milliliters per hour intravenously every shift for acute kidney injury, dehydration, and C difficile times three days (10/13 through 10/16) - Flagyl 500 milligrams per 10ML. Provide 500 milligrams intravenously every six hours for Enterocolitis due to C difficile (10/14/23 x 2 doses, 10/15/23-10/23/23 x 4 doses, and 10/24/23 x 1 dose) - Flagyl 500 mg by mouth twice daily for C difficile (10/24/23 x 2 doses) - Polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation (10/25/23-10/31/23) A nurse progress note written by Nurse #5 dated 10/29/23 indicated Resident #1 was noted to have yellow liquid jelly like stool. The note also indicated Resident #1 had recently stopped IV antibiotics for C-difficile and a stool sample had been collected. The note did not indicate that a Medical Provider was contacted about the ongoing loose stools or that the order had been obtained from the Medical Provider for the stool culture. A review of the daily nurse assignment sheets indicated Nurse #5 was being oriented by Nurse #1 on 10/29/23. Nurse #5 was unavailable for interview. An interview on 11/20/23 at 11:30 AM with Nurse #1 revealed she had been the primary day shift nurse (7:00 AM to 7:00 PM) on the South Unit on 10/29/23 where Resident #1 resided. Nurse #1 indicated she recalled Resident #1 was positive for C difficile and had been transferred to her unit last month due to requirements of isolation for the infection. Nurse #1 stated Resident #1 was, at baseline, alert and oriented x 4 (person, place, time and event), incontinent of bowel and bladder and had frequent loose stools containing a mucus while on her unit. Nurse #1 said that she recalled Resident #1 continued to have loose stools after being taken off precautions and therefore on 10/29/23, she placed a note in the medical provider's binder to alert them of the ongoing loose stools so they would provide an order for the laboratory test for C-Difficile but did not contact a Medical Provider in person or via telephone. Nurse #1 explained she obtained a stool sample at that time and sent it to the laboratory to test for C-Difficile. Attempts were made to interview Nurse #8 who worked 10/29/23 (7:00 PM- 7:00 AM) without success. Nurse Aide documentation dated 10/29/23 reflected Resident #1 had four loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated 10/30/23 indicated Resident #1's orientation (ability to recall person, place, time, and event) changed throughout the day and had semi formed stools on day shift. The note did not reflect the Medical Provider was notified of the ongoing loose stools or Resident #1's orientation changes. An interview with Nurse #4 on 11/28/23 at 9:00 AM revealed worked day shift on 10/30/23 and she could not recall the resident other than what was charted regarding orientation changes. She recalled throughout Resident #1's stay, she experienced diarrhea so frequently that after a while she no longer got out of bed. Nurse Aide documentation dated 10/30/23 reflected Resident #1 had six loose/diarrhea stools. An interview on 11/20/23 at 11:25 AM with Nurse Aide (NA) #1 revealed she had worked the unit where Resident #1 resided for approximately 4 months on day shift and documented on the following days in October 2023: 10/13/23, 10/14/23, 10/15/23, 10/19/23, 10/24/23, 10/28/23, and 10/29/23. NA#1 indicated she could not recall any specific day, but Resident #1 was normally alert and oriented, able to make her needs known, incontinent of bowel and bladder with multiple loose stools which frequently contained mucous the entire time she had been on the South Unit. NA #1 stated she made Nurse #1 aware of the ongoing loose stools. An interview with Nurse Aide #2 (NA #2) on 11/20/23 at 11:55 AM revealed that she worked on the South unit on night shift and documented on 10/17/23, 10/18/23, 10/22/23, 10/23/23, 10/26/23, 10/27/23, and 10/31/23. NA #2 indicated Resident #1 was alert and oriented but rang the call light frequently due to loose stools. NA #2 described the stools as slimy and thick. NA #2 stated she made the nurse aware of loose stools but could not recall the names of each nurse daily. An interview with Nurse Aide #3 (NA #3) on 11/20/23 at 1:45 PM revealed she worked on the South unit where Resident #1 resided and documented on night shift on the following dates in October 2023: 10/16/23, 10/19/23, 10/20/23, 10/24/23, 10/25/23, 10/28/23, 10/29/23, 10/30/23. NA #3 stated Resident #1 diarrhea and mucous like stools on each shift she worked and had alerted the nurse on duty each shift but could not recall the names of all nurses she alerted. A laboratory report dated 10/30/23 indicated Resident #1 was positive for C difficile. The report reflected the laboratory notified the facility of the abnormal lab and spoke with Nurse #2 on 10/30/23 at 9:34 PM. The report indicated it was reviewed by the Physician's Assistant on 10/31/23 at 1:18 PM. It however did not indicate a provider was notified of the abnormality on 10/30/23 when the laboratory notified Nurse #2 of the critical results. A review of Resident #1's medical record revealed she was not seen by a facility Medical Provider after the abnormal C. difficile result. Attempts were made to interview Nurse #2 without success. A review of Resident #1's medical record did not reflect Nurse #2 assessed Resident #1. The review of the nurses' progress notes indicated Nurse #2 had not notified the MD or NP of the abnormal lab or received any orders for medical interventions. An interview with the PA on 11/21/23 at 11:20 AM revealed she was not familiar with Resident #1 and had not provided her with any direct care. The PA stated because a resident can test positive for C-Difficile for up to 90 days she would not have treated her with Resident #1 experiencing ongoing intermittent loose stools. A review of Resident #1's medical record revealed the last time she was seen by a medical provider was on 10/27/23 and there were no physician orders for the treatment of C-Difficile colitis after the positive test results were received. An interview with the Nurse Practitioner (NP) on 11/21/23 at 3:24 PM and 4:02 PM revealed she was familiar with Resident #1 and recalled her to be alert and oriented x 4 (accurately aware of person, place, time and event). The NP stated shortly after her admission she began having loose stools and she ordered a laboratory test for C-Difficile which resulted as positive, and treatment was ordered at the time. The NP indicated the treatment was for Vancomycin oral and Flagyl both IV and oral. The NP recalled Resident #1 continuing to have loose stools but thought another provider had placed her on treatment following the second positive stool culture and therefore did not order any further treatment. The NP could not recall anything other than thinking another provider had handled the 2nd C-Diff lab nor being aware of orientation changes noted on 10/30/23. An interview with the Physician (MD) on 11/21/23 at 4:08 PM revealed he was aware Resident #1 had been treated for C-Difficile shortly after her admission; however, he had not been made aware of the abnormal laboratory results on 10/30/23 and did not prescribe treatment for the ongoing loose stools. The MD stated the ongoing loose stools could have been exacerbated from the Polyethylene glycol prescribed by the surgeon at Resident #1's follow-up appointment on 10/25/23. He acknowledged the only visit he had with Resident #1 was on 10/12/23. He did not recall any further updates to Resident #1's condition. The MD indicated he would expect the lab to be reviewed by the PA and proper monitoring or interventions to be placed. A nurse's progress note dated 10/31/23 indicated Resident #1 had semi formed stools on day shift. The note did not indicate a Medical Provider was notified of the stools. Nurse Aide documentation dated 10/31/23 reflected Resident #1 had seven loose/diarrhea stools. A review of the MAR dated November 2023 indicated Resident #1 received the following: - Lisinopril 10mg daily (11/1/23 through 11/7/23) - Loperamide 2 mg tablet after each loose stool as needed for diarrhea x 1 day (11/3/23) - Cholestyramine Light Oral Packet 4 GM give one packet by mouth one time a day related to diarrhea (11/1/23 through 11/7/23) - Polyethylene glycol 17 grams per scoop. Give one scoop by mouth one time a day related to Constipation (11/1/23, 11/3/23, 11/4/23) A nurse progress note written by Nurse #1 dated 11/1/23 indicated Resident #1 was alert and oriented with a blood pressure of 137/65. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with diarrhea. The note indicated MD was aware and staff should continue to monitor. Nurse Aide documentation dated 11/1/23 reflected Resident #1 had six loose/diarrhea stools. A nurse's progress note written by Nurse #1 dated 11/2/23 indicated Resident #1 was alert and oriented and her BP was 121/79. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had loose stools during day shift and Polyethylene glycol was held due to loose stools. The note did not indicate a Medical Provider was notified of the loose stools or that Polyethylene glycol was held. Nurse Aide documentation dated 11/2/23 reflected Resident #1 had eight loose/diarrhea stools. A late entry nurse's progress note written by Nurse #4 dated 11/3/23 indicated Resident #1 was alert and oriented with inconsistent cognitive status and her blood pressure was 110/54. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. The note did not indicate a Medical Provider was notified of the loose stools. Nurse Aide documentation dated 11/3/23 reflected Resident #1 had thirteen loose/diarrhea stools. An interview on 11/20/23 at 11:25 AM with Nurse Aide (NA) #1 revealed she had worked the unit where Resident #1 resided for approximately 4 months on day shift and was on duty on the following days in November 2023: 11/1/23 and 11/2/23. NA #1 indicated she had made the hall nurse on duty aware of the ongoing loose stools each shift although she could not recall the names of each nurse daily. A nurse's progress note written by Nurse #4 dated 11/4/23 indicated Resident #1 was alert and oriented with inconsistent cognitive status and her blood pressure was 110/54. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. The note did not indicate a Medical Provider was notified of the loose stools. Nurse Aide documentation dated 11/4/23 reflected Resident #1 had one loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated 11/5/23 did not indicate Resident #1's cognitive status Her blood pressure was listed as 90/50. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. The note did not indicate a Medical Provider was notified of the loose stools or that Resident #1 had experienced a low blood pressure. An interview with Nurse #4 on 11/28/23 at 9:00 AM revealed she could not recall the resident other than what was charted regarding orientation changes or low blood pressure. She recalled throughout Resident #1's stay, she experienced diarrhea so frequently that after a while she no longer got out of bed. Nurse Aide documentation dated 11/5/23 reflected Resident #1 had six loose/diarrhea stools. A nurse's progress note written by Nurse #2 dated 11/6/23 indicated on night shift (11/5 at 7:00 PM through 11/6 at 7:00 AM) Resident #1 was alert and oriented and able to make needs known. Resident#1 had a blood pressure of 110/56. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during night shift. The note indicated Loperamide was administered without any favorable effects. The note did not indicate a Medical Provider was notified of the loose stools or that Loperamide had to be administered. Attempts to interview Nurse #2 were unsuccessful. A nurse's Progress note written by Nurse #1 dated 11/6/23 indicated Resident #1's Polyethylene glycol was held secondary to loose stools on day shift. The note did not indicate a Medical Provider was notified of the loose stools or that Polyethylene glycol was held. A nurse progress note written by Nurse #1 dated 11/6/23 indicated Resident #1 was alert and oriented and able to make her needs known. Resident #1's blood pressure was 161/88. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during day shift and Polyethylene Glycol was held secondary to loose stools. The note did not indicate a Medical Provider was notified of the loose stools or that Polyethylene glycol was held. A review of Resident #1's medical record revealed no progress notes written by Nurse #3 on 11/6/23. A telephone interview with Nurse #3 on 11/21/23 at 9:38 AM revealed she acknowledged she worked the South unit on 11/6/23 on night shift but could not recall Resident #1 to include any stools or behaviors on 11/6/23 due to her working all the units and her working on an as needed basis only. She could not recall notifying the Medical Provider of Resident #1's loose stools, change in cognition, or behaviors. Nurse Aide documentation dated 11/6/23 reflected Resident #1 had six loose/diarrhea stools. An interview with Nurse Aide #2 (NA #2) on 11/20/23 at 11:55 AM revealed that she worked on the South unit on night shift and documented on the following dates in November 2023: 11/1/23, 11/4/23, 11/5/23, and 11/6/23. NA #2 indicated Resident #1 was alert and oriented but rang the call light frequently due to loose stools. NA #2 described the stools as slimy and thick. NA #2 stated she was aware Resident #1 had C-Difficile and therefore alerted Nurse #2 of the resident having loose stools but did not alert the nurse with each loose stool because they were aware of them. An interview with Nurse Aide #3 (NA #3) on 11/20/23 at 1:45 PM revealed she worked on the South unit where Resident #1 resided on night shift on 11/6/23. NA #3 stated on the night of 11/6/23, Resident #1 was more confused than normal. She indicated during her shift, Resident #1 continued to have mucous stools but did not ring her light to be changed as she normally would, was disoriented and trying to climb out of bed. NA #3 said she told Nurse #2. Attempts were made to contact Nurse #2 without success. A review of Resident #1's medical record did not reflect Nurse #2 assessed Resident #1. The review indicated Nurse #2 had not notified the MD or NP of the abnormal lab or received any orders for medical interventions. Attempts to interview Nurse #2 were unsuccessful. Nurse Aide documentation dated 11/7/23 reflected Resident #1 eight had loose/diarrhea stools. A nurse's Progress note written by Nurse #1 dated 11/7/23 at 2:30 PM indicated Resident #1 was alert and oriented and able to make her needs known. Resident #1's blood pressure was 107/48. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during day shift and Polyethylene Glycol was held secondary to loose stools. The note did not indicate a Medical Provider was notified of the loose stools or that Polyethylene glycol was held. A late entry nurse progress note written by Nurse #1 on 11/13/23 at 3:19 PM indicated on 11/7/23 at approximately 3:30 PM, Nurse #1 was informed that Resident #1 had a low blood pressure and appeared confused. The note indicated Nurse #1 assessed Resident #1's blood pressure manually and found the value to be at baseline for the patient at 106/51. Confusion noted also to be at baseline. The note did not indicate a Medical Provider was notified of Resident #1's low blood pressure, lethargy, confusion, behaviors, her inability to take her morning medications, or ongoing loose stools. An interview on 11/20/23 at 1:00 PM with Physical Therapy Assistant #1 revealed he was assigned to Resident #1's therapy treatment for physical therapy on 11/7/23. PTA #1 indicated when he entered the room between 3:00 and 4:00 PM, he noticed Resident #1 was not herself as she had previously had a very social based personality when he had worked with her a couple of weeks prior. PTA #1 indicated on this date, Resident #1 appeared more lethargic and confused. PTA #1 stated he made attempts to sit Resident #1 on the edge of the bed thinking she would arouse to her normal self with stimulation. He indicated he alerted Certified Occupational Therapy Assistant (COTA #1) who was nearby and asked him to look at obvious concerns of Resident #1's change from the previous time he had worked with her. He indicated that COTA #1 entered the room and agreed that Resident #1 was not at her baseline as he routinely provided therapy for her. During this discussion between PTA #1 and COTA #1, Nurse #1 entered the room to give Resident #1 her medications. He said he mentioned to Nurse #1 that Resident #1 was acting different, but the nurse did not respond to his statement. PTA #1 stated when medications were administered by Nurse #1, [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and family, staff, Nurse Practitioner (NP), Physician Assistant (PA), and physician (MD) interviews, the facility failed to complete comprehensive assessments and determine the need for medical interventions for a resident who continued to experience loose stools post antibiotic treatment for Clostridium Difficile (C-Difficile) which ended on 10/24/23. (C-difficile is a bacterium that causes an infection of the colon. Symptoms can range from diarrhea to life-threatening damage to the colon.). The afternoon of 11/07/23 the resident had a significant change in condition including increased lethargy and confusion, low blood pressure, spitting out her pills and hollering out. There was no comprehensive assessment completed to determine if there was the need to seek medical attention. Staff did not recognize the significant change in condition until late in the evening on 11/07/23 and the resident was sent to the hospital for an evaluation. Hospital records dated 11/7/23 indicated the resident was diagnosed with sepsis with acute organ dysfunction, acute encephalopathy secondary to infectious process, hypothermia, and type 2 myocardial infarction (heart attack). The resident expired on 11/10/23. This deficient practice occurred for 1 of 2 residents reviewed for quality of care/providing care according to professsional standards (Resident #1). The immediate jeopardy began on 11/7/23 when the facility failed to effectively respond to and seek medical attention when Resident #1 had a significant change in condition. The immediate jeopardy was removed on 11/23/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D no actual harm to ensure the completion of education and monitoring systems put into place are effective. This deficient practice occurred for 1 of 2 residents reviewed for quality of care. The findings included: A hospital Discharge summary dated [DATE] indicated Resident #1 presented to the emergency room (ER) with abdominal pain and vomiting which required abdominal surgery for the gallstones. The discharge summary reflected Resident #1 received intravenous (IV) antibiotics for chronic leukocytosis (high white blood cell count) (WBC 11.41) and cholecystitis (inflammation of the gall bladder) which was corrected with the cholecystectomy (surgical removal of the gallbladder). It also listed cystitis without hematuria as resolved and orders for Amoxicillin-Clavulanate (antibiotic) 500-125 milligrams (mg) 1 tablet by mouth every 8 hours for 3 days. Resident #1 was admitted to the facility on [DATE] with diagnoses that included status post cystitis without hematuria (bladder inflammation without blood present in the urine) and surgical intervention of calculus of the bile duct with chronic cholecystitis without obstruction (gallstones) and abdominal hernia without obstruction or gangrene and hypertension. A physician's order dated 10/5/23 indicated Amoxicillin 500-125 milligrams (mg) three times per day for 3 days for cystitis. Additionally, Lisinopril 10mg daily by mouth was ordered for hypertension. A one-day post admission progress note dated 10/6/23 written by the NP indicated Resident #1 was admitted to the facility after being hospitalized from [DATE] through 10/5/23 status post endoscopic retrograde cholangiopancreatography (a procedure using a scope to diagnose and treat problems of the biliary or pancreatic system) on 9/28/23 and cholecystitis with choledocholithiasis (gallstones), incarcerated hiatal hernia (part of intestine trapped in the sac of a hernia which can become life threatening if untreated) on 10/3/23. The note indicated Resident #1 was to receive Amoxicillin 500/125 by mouth three times per day from 10/6/23 through 10/9/23. The note also indicated she was positive for constipation as she was pushing and straining to have a bowel movement last night (10/5/23) with her abdomen soft, non-tender, and without hepatospleenomegaly. The note also revealed Resident #1 had hospital labs on 10/4/23 which indicated the following values: slightly elevated white blood cells (WBC) 12.07 and a normal creatinine level of 0.9. The assessment listed the following: negative for behaviors, no gastrointestinal (GI) upset with ability to tolerate foods and liquids, and hypertension with systolic blood pressures ranging between 120's to 140's on treatment of Lisinopril daily and monitor blood pressure daily. A physician's order dated 10/7/23 indicated Loperamide 2 mg tablet after each loose stool as needed for diarrhea x 1 day. A review of the nurses' progress notes for 10/07/23 revealed nothing related to loose stools. A skilled progress note written by Nurse #7 dated 10/8/23 at 4:23 PM indicated Resident #1 complained of loose stool after lunch. A review of the Medication Administration Record (MAR) dated October 2023 indicated Resident #1 received Loperamide 2mg on 10/7/23 at 10:29 AM by Nurse #6 and again on 10/8/23 at 5:14 PM by Nurse #7. Attempts to contact Nurse #6 were unsuccessful. An interview on 11/28/23 at 10:00 AM with Nurse #7 revealed she could not recall Resident #1 as she was moved to the South Unit shortly after admission and Nurse #7 had no further involvement with her care. A provider progress note written by the NP on 10/9/23 indicated Resident #1 was seen for a 3-day post admission visit. The note indicated Resident #1 was not feeling well and had complained that loose stools began over the weekend, and she had already experienced 3 diarrhea water stools that day. Resident #1 complained of abdominal pain but no nausea or vomiting. Resident #1 felt bloated with indigestion. The note indicated Resident #1 had reported a history of C-Difficile on 2/20/23. Orders were provided to obtain a stool specimen to test for C-Difficile and discontinue Loperamide that was administered over the weekend. A physician order dated 10/9/23 indicated obtain stool specimen to test for C-Difficile. A laboratory report dated 10/10/23 indicated Resident #1 was positive for C -difficile colitis. A progress note was written by the NP on 10/11/23 for a 5-day post admission visit. The note indicated Resident #1 continued to complain of diarrhea, abdominal pain, and indigestion. C-Difficile culture continued to be pending at the time of the visit. Resident #1 is currently not able to eat well. Continues to have a soft, non-tender abdomen with hyperactive bowels sounds and negative for bladder distention. The note indicated Resident #1 had experienced 6 watery stools the day prior to the visit. New orders were received to start Cholestyramine 1 packet orally daily and continue to monitor Resident #1's condition pending C-Difficile laboratory results. The note further indicated Resident #1 had blood pressure of 136/66 and to continue the Lisinopril as ordered. A nurse progress note written by the Unit Manager dated 10/11/23 indicated she spoke with the family member regarding Resident #1's abnormal lab results and testing positive for C-Difficile colitis and antibiotic therapy would be initiated. A physician's order dated 10/11/23 indicated Cholestyramine (used for bile acid diarrhea) Light Oral Packet 4 grams (GM) give one packet by mouth one time a day related to diarrhea. A physician's order dated 10/11/23 indicated Vancomycin (antibiotic) 125 milligrams give one tablet four times a day for C-difficile. The order was discontinued on 10/12/23. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact and no behaviors were noted. An admission History and Physical (H&P) written by the MD dated 10/12/23 indicated Resident #1 was positive for diarrhea, negative for confusion, and negative for dysuria or bladder distension. It also revealed Resident #1's abdomen was soft, non-tender, and no guarding or rebound present with normal cognition with good memory recall both recent and remote. The note stated Resident #1 had a laboratory test on 10/10/23 which was positive for C-Difficile. A laboratory report dated 10/12/23 indicated Resident #1's white blood cell (test to determine immune ability to fight infection) count was elevated to 26.7 (normal being 4.1 to 10.9), Creatinine (test for kidney function) was normal at 1.16 (normal being 0.5 to 1.20) and C-reactive protein was 28.70 (test for inflammation in the body- normal being less than 0.50). A provider progress note written by the NP dated 10/13/23 indicated Resident #1 had been placed on quarantine for C-Difficile and continued to have watery stools, abdominal pain, and now nausea. Laboratory results were reviewed with the following noted: elevated WBC of 26.7, low calcium at 8, elevated BUN 21.1, normal creatinine at 1.16, low sodium at 132, and a high CRP of 28.7. At this visit, Resident #1 was positive for weakness and fatigue, decrease strength and mobility, and negative for confusion or bladder distension. Resident #1's plan of care listed included the following: Start IV fluids (Normal Saline 60 cubic centimeters (cc) per hour for 48 hours) secondary to a low sodium level. Repeat CBC and CMP on Monday (10/16/23) to compare for trends. Resident was previously prescribed Vancomycin, but secondary to high WBC she was switched to Flagyl 500mg every 6 hours x 7 days. Discontinue Vancomycin once Flagyl has started. At this visit, Resident #1's blood pressures were reviewed to be between 120's and 140's systolic and continued on Lisinopril. A physician's order dated 10/13/23 indicated Sodium Chloride 0.45% intravenous. Give 60 milliliters per hour for 3 days for dehydration, acute kidney injury and C-Difficile. The order was discontinued on 10/16/23. A physician's order dated 10/13/23 indicated Flagyl (antibiotic) 500 mg per 100 milliliters (ML). Provide 500 mg (IV) intravenously every six hours for Enterocolitis due to C-difficile for 7 days. A laboratory report dated 10/16/23 indicated Resident #1's white blood cell count was normal at 9.0, C-reactive protein remained elevated at 15.8 and Creatinine was normal at 0.90. A provider progress note written by the NP dated 10/16/23 indicated Resident #1 was seen for a 14-day post admission visit. The note indicated during this visit Resident #1 remained on IV fluids which completed 10/16/23 and Flagyl via midline IV and reported the diarrhea was uncontrollable. A review of the laboratory results dated [DATE] listed the following values: white blood cell count was normal at 9.0, C-reactive protein remained elevated at 15.8 and Creatinine was normal at 0.90. The plan of care included the following: Continue Flagyl until completed and addressed a significant improvement in Resident #1's laboratory results with a normal WBC and improving BUN, Creatinine, and sodium levels. The note also indicated Resident #1's blood pressure remained between 120's and 140's systolic and continued on Lisinopril for treatment. No new orders were given on this visit. A provider progress note written by the NP dated 10/20/23 indicated Resident #1 had a slight improvement but continued to have diarrhea with staff reports of decrease odorous stools. New orders included: extend the Flagyl IV for a total of 10 days. A physician's order dated 10/20/23 indicated Flagyl (antibiotic) 500 mg per 100 milliliters (ML). Provide 500 mg (IV) intravenously every six hours for Enterocolitis due to C-difficile for an additional 3 days. A physician's order dated 10/24/23 indicated Flagyl 500 mg by mouth twice daily for C-difficile. The order was discontinued on 10/25/23. A surgeon's consultation form dated 10/25/23 indicated Resident #1 was seen for a follow up with constipation and new orders were given for polyethylene glycol 17 grams per scoop, a laxative used to treat occasional constipation and soften stool. Give one scoop by mouth once a day related to constipation. A nurse progress note written by Nurse #4 dated 10/25/23 indicated Resident #1 was seen for a surgical consult and new orders to advance diet and give polyethylene glycol 17 grams per scoop, a laxative used to treat occasional constipation and soften stool. Give one scoop by mouth once a day related to constipation. An interview with Nurse #4 on 11/28/23 at 9:00 AM revealed she could not recall the order provided by the surgical consult but entered as previously educated from the surgical consultation communication form. Nurse #4 did not question the order because the antibiotic treatment for C-Difficile was completed. A physician's order dated 10/25/23 indicated polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation. A provider note written by the NP dated 10/27/23 indicated Resident #1 was seen for a 21-day post admission visit. The noted reflected Resident #1 had improved with GI symptoms but continued with on and off diarrhea mixed with some semi-formed stools. The note indicated Resident #1's had completed her IV antibiotics. The note also indicated Resident #1's blood pressure remained between 120's and 140's systolic and continued Lisinopril for treatment. No new orders were given on this visit. A review of the Medication Administration Record (MAR) dated October 2023 indicated Resident #1 received the following: - Amoxicillin/Clavulanate 500-125 mg one tablet every 8 hours for 3 days (10/6/23 through 10/8/23 for a total 8 doses) - Lisinopril 10 mg daily (10/6/23 through 10/31/23 except 10/20/23, 10/21/23, and 10/22/23 because BP was outside of the parameters) - Loperamide 2 mg tablet after each loose stool as needed for diarrhea x 1 day (10/7/23 and 10/8/23) - Cholestyramine Light Oral Packet 4 GM give one packet by mouth one time a day related to diarrhea (10/12 through 10/31) - Vancomycin 125 milligrams give one tablet. Four times a day for C difficile (10/12 and 10/13) - Sodium chloride intravenous solution 0.4%. Used 60 milliliters per hour intravenously every shift for acute kidney injury, dehydration, and C difficile times three days (10/13 through 10/16) - Flagyl 500 milligrams per 10ML. Provide 500 milligrams intravenously every six hours for Enterocolitis due to C difficile (10/14/23 x 2 doses, 10/15/23-10/23/23 x 4 doses, and 10/24/23 x 1 dose) - Flagyl 500 mg by mouth twice daily for C difficile (10/24/23 x 2 doses) - Polyethylene glycol 17 grams per scoop. Give one scoop by mouth once a day related to constipation (10/25/23-10/31/23) A nurse progress note written by Nurse #5 dated 10/29/23 indicated Resident #1 was noted to have yellow liquid jelly like stool. The note also indicated Resident #1 had recently stopped IV antibiotics for C-difficile and a stool sample had been collected. A review of the daily nurse assignment sheets indicated Nurse #5 was being oriented by Nurse #1 on 10/29/23. Nurse #5 was unavailable for interview. An interview on 11/20/23 at 11:30 AM with Nurse #1 revealed she had been the primary day shift nurse (7:00 AM to 7:00 PM) on the South Unit on 10/29/23 where Resident #1 resided. Nurse #1 indicated she recalled Resident #1 was positive for C difficile and had been transferred to her unit last month due to requirements of isolation for the infection. Nurse #1 stated Resident #1 was, at baseline, alert and oriented x 4 (person, place, time and event), incontinent of bowel and bladder and had frequent loose stools containing a mucus while on her unit. Nurse #1 said that she recalled Resident #1 continued to have loose stools after being taken off precautions and therefore on 10/29/23, she placed a note in the medical provider's binder to alert them of the ongoing loose stools so they would provide an order for the laboratory test for C-Difficile. Nurse #1 explained she obtained a stool sample at that time and sent it to the laboratory to test for C-Difficile. Attempts were made to interview Nurse #8 who worked 10/29 (7:00 PM- 7:00 AM) without success. Nurse Aide documentation dated 10/29/23 reflected Resident #1 had four loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated 10/30/23 indicated Resident #1's orientation (ability to recall person, place, time, and event) changed throughout the day and had semi formed stools on day shift. An interview with Nurse #4 on 11/28/23 at 9:00 AM revealed worked day shift on 10/30/23 and she could not recall the resident other than what was charted regarding orientation changes. Nurse Aide documentation dated 10/30/23 reflected Resident #1 had six loose/diarrhea stools. An interview on 11/20/23 at 11:25 AM with Nurse Aide (NA) #1 revealed she had worked the unit where Resident #1 resided for approximately 4 months on day shift and documented on the following days in October 2023: 10/13/23, 10/14/23, 10/15/23, 10/19/23, 10/24/23, 10/28/23, and 10/29/23. NA#1 indicated she could not recall any specific day, but Resident #1 was normally alert and oriented, able to make her needs known, incontinent of bowel and bladder with multiple loose stools which frequently contained mucous the entire time she had been on the South Unit. NA #1 stated she made Nurse #1 aware of the ongoing loose stools. An interview with Nurse Aide #2 (NA #2) on 11/20/23 at 11:55 AM revealed that she worked on the South unit on night shift and documented on 10/17/23, 10/18/23, 10/22/23, 10/23/23, 10/26/23, 10/27/23, and 10/31/23. NA #2 indicated Resident #1 was alert and oriented but rang the call light frequently due to loose stools. NA #2 described the stools as slimy and thick. NA #2 stated she made the nurse aware of loose stools but could not recall the names of each nurse daily. An interview with Nurse Aide #3 (NA #3) on 11/20/23 at 1:45 PM revealed she worked on the South unit where Resident #1 resided and documented on night shift on the following dates in October 2023: 10/16/23, 10/19/23, 10/20/23, 10/24/23, 10/25/23, 10/28/23, 10/29/23, 10/30/23. NA #3 stated Resident #1 diarrhea and mucous like stools on each shift she worked and had alerted the nurse on duty each shift but could not recall the names of all nurses she alerted. A laboratory report dated 10/30/23 indicated Resident #1 was positive for C-difficile. The report reflected the laboratory notified the facility of the abnormal lab and spoke with Nurse #2 on 10/30/23 at 9:34 PM. The report indicated it was reviewed by the Physician Assistant on 10/31/23 at 1:18 PM. Attempts were made to interview Nurse #2 without success. A review of Resident #1's medical record did not reflect Nurse #2 assessed Resident #1. The review indicated Nurse #2 had not notified the MD or NP of the abnormal lab or received any orders for medical interventions. An interview with the PA on 11/21/23 at 11:20 AM revealed she was not familiar with Resident #1 and had not provided her with any direct care. The PA stated because a resident can test positive for C-Difficile for up to 90 days she would not have treated her with ongoing intermittent loose stools. A review of Resident #1's medical record revealed the last time she was seen by a medical provider was on 10/27/23 and there were no physician orders for the treatment of C-Difficile colitis after the positive test results were received on 10/30/23. An interview with the Nurse Practitioner (NP) on 11/21/23 at 3:24 PM and 4:02 PM revealed she was familiar with Resident #1 and recalled her to be alert and oriented x 4. The NP stated shortly after admission she began having loose stools and she ordered a laboratory test for C-Difficile which resulted as positive, and treatment was ordered at the time. The NP indicated the treatment was for Vancomycin oral and Flagyl both IV and oral. The NP recalled Resident #1 continuing to have loose stools but thought another provider had placed her on treatment and therefore did not order any further treatment. The NP could not recall anything other than thinking another provider had handled the 2nd C-Diff lab nor being aware of orientation changes noted on 10/30/23. An interview with the Physician (MD) on 11/21/23 at 4:08 PM revealed he was aware Resident #1 had been treated for C-Difficile shortly after her admission; however, he had not been made aware of the abnormal laboratory results on 10/30/23 and did not prescribe treatment for the ongoing loose stools. The MD stated the ongoing loose stools could have been exacerbated from the Polyethylene glycol prescribed by the surgeon at Resident #1's follow-up appointment on 10/25/23. He acknowledged the only visit he had with Resident #1 was on 10/12/23. He did not recall any further updates to Resident #1's condition. The MD indicated he would expect the lab to be reviewed by the PA and proper monitoring or interventions to be placed. A nurse's progress note dated 10/31/23 indicated Resident #1 had semi formed stools on day shift. Nurse Aide documentation dated 10/31/23 reflected Resident #1 had seven loose/diarrhea stools. A review of the MAR dated November 2023 indicated Resident #1 received the following: - Lisinopril 10mg daily (11/1/23 through 11/7/23) - Loperamide 2 mg tablet after each loose stool as needed for diarrhea x 1 day (11/3/23) - Cholestyramine Light Oral Packet 4 GM give one packet by mouth one time a day related to diarrhea (11/1/23 through 11/7/23) - Polyethylene glycol 17 grams per scoop. Give one scoop by mouth one time a day related to Constipation (11/1/23, 11/3/23, 11/4/23) A nurse progress note written by Nurse #1 dated 11/1/23 indicated Resident #1 was alert and oriented with a blood pressure of 137/65. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with diarrhea. The note indicated MD was aware and staff should continue to monitor. Nurse Aide documentation dated 11/1/23 reflected Resident #1 had six loose/diarrhea stools. A nurse's progress note written by Nurse #1 dated 11/2/23 indicated Resident #1 was alert and oriented and her BP was 121/79. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had loose stools during day shift and Polyethylene glycol was held due to loose stools. Nurse Aide documentation dated 11/2/23 reflected Resident #1 had eight loose/diarrhea stools. An interview on 11/20/23 at 11:25 AM with Nurse Aide (NA) #1 revealed she had worked the unit where Resident #1 resided for approximately 4 months on day shift and was on duty on the following days in November 2023: 11/1/23 and 11/2/23. NA #1 indicated she had made the hall nurse on duty aware of the ongoing loose stools each shift although she could not recall the names of each nurse daily. A late entry nurse's progress note written by Nurse #4 dated 11/3/23 indicated Resident #1 was alert and oriented with inconsistent cognitive status and her blood pressure was 110/54. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. Nurse Aide documentation dated 11/3/23 reflected Resident #1 had thirteen loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated 11/4/23 indicated Resident #1 was alert and oriented with inconsistent cognitive status and her blood pressure was 110/54. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. Nurse Aide documentation dated 11/4/23 reflected Resident #1 had one loose/diarrhea stools. A nurse's progress note written by Nurse #4 dated 11/5/23 did not indicate Resident #1's cognitive status. Her blood pressure was listed as 90/50. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and Resident #1 had incontinence with a mixture of diarrhea stools and semi formed stools during day shift. An interview with Nurse #4 on 11/28/23 at 9:00 AM revealed she recalled throughout Resident #1's stay, she experienced diarrhea so frequently that after a while she no longer got out of bed. Nurse Aide documentation dated 11/5/23 reflected Resident #1 had six loose/diarrhea stools. A nurse's progress note written by Nurse #2 dated 11/6/23 indicated on night shift (11/5/23 at 7:00 PM through 11/6/23 at 7:00 AM) Resident #1 was alert and oriented and able to make needs known. Resident#1 had a blood pressure of 110/56. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during night shift. The note indicated Imodium AD was administered without any favorable effects. Attempts to interview Nurse #2 were unsuccessful. A nurse progress note written by Nurse #1 dated 11/6/23 indicated Resident #1 was alert and oriented and able to make her needs known. Resident #1's blood pressure was 161/88. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during day shift and Polyethylene Glycol was held secondary to loose stools. A review of Resident #1's medical record revealed no progress notes written by Nurse #3 on 11/6/23. A telephone interview with Nurse #3 on 11/21/23 at 9:38 AM revealed she acknowledged she worked the South unit on 11/6/23 on night shift but could not recall Resident #1 to include any stools or behaviors on 11/6/23 due to her working all the units and her working on an as needed basis only. Nurse Aide documentation dated 11/6/23 reflected Resident #1 had six loose/diarrhea stools. An interview with NA #2 on 11/20/23 at 11:55 AM revealed that she worked on the South unit on night shift and documented on the following dates in November 2023: 11/1/23, 11/4/23, 11/5/23, and 11/6/23. NA #2 indicated Resident #1 was alert and oriented but rang the call light frequently due to loose stools. NA #2 described the stools as slimy and thick. NA #2 stated she was aware Resident #1 had C-Difficile and therefore alerted Nurse #2 of the resident having loose stools but did not alert the nurse with each loose stool because they were aware of them. An interview with NA #3 on 11/20/23 at 1:45 PM revealed she worked on the South unit where Resident #1 resided on night shift on 11/6/23. NA #3 stated on the night of 11/6/23, Resident #1 was more confused than normal. She indicated during her shift, Resident #1 continued to have mucous stools but did not ring her light to be changed as she normally would, was disoriented and trying to climb out of bed. NA #3 said she told Nurse #2. A review of Resident #1's medical record did not reflect Nurse #2 assessed Resident #1. The review indicated Nurse #2 had not notified the MD or NP of the abnormal lab or received any orders for medical interventions. Attempts were made to interview Nurse #2 without success. Nurse Aide documentation dated 11/7/23 reflected Resident #1 eight had loose/diarrhea stools. A nurse's Progress note written by Nurse #1 dated 11/7/23 at 2:30 PM indicated Resident #1 was alert and oriented and able to make her needs known. Resident #1's blood pressure was 107/48. A gastrointestinal observation revealed all 4 quadrants of the abdomen were normal and she had multiple loose stools during day shift and Polyethylene Glycol was held secondary to loose stools. A late entry nurse progress note written by Nurse #1 on 11/13/23 at 3:19 PM indicated on 11/7/23 at approximately 3:30 PM, Nurse #1 was informed that Resident #1 had a low blood pressure and appeared confused. The note indicated Nurse #1 assessed Resident #1's blood pressure manually and found the value to be at baseline for the patient at 106/51. Confusion noted also to be at baseline. An interview on 11/20/23 at 1:00 PM with Physical Therapy Assistant #1 revealed he was assigned to Resident #1's therapy treatment for physical therapy on 11/7/23. PTA #1 indicated when he entered the room between 3:00 and 4:00 PM, he noticed Resident #1 was not herself as she had previously had a very social based personality when he had worked with her a couple of weeks prior. PTA #1 indicated on this date, Resident #1 appeared more lethargic and confused. PTA #1 stated he made attempts to sit Resident #1 on the edge of the bed thinking she would arouse to her normal self with stimulation. He indicated he alerted Certified Occupational Therapy Assistant (COTA #1) who was nearby and asked him to look at obvious concerns of Resident #1's change from the previous time he had worked with her. He indicated that COTA #1 entered the room and agreed that Resident #1 was not at her baseline as he routinely provided therapy for her. During this discussion between PTA #1 and COTA #1, Nurse #1 entered the room to give Resident #1 her medications. He said he mentioned to Nurse #1 that Resident #1 was acting different, but the nurse did not respond to his statement. PTA #1 stated when medications were administered by Nurse #1, Resident #1 spit the medications out, the nurse collected the pills, and the nurse left the room. PTA #1 indicated Resident #1 continued to remain confused and uncooperative with therapy after the nurse left the room. He explained he and COTA #1 obtained vital signs using the robot-nurse. He stated it took them approximately 20 minutes or so to obtain two blood pressures due to Resident #1 was fidgety and restless. Resident #1's blood pressure was obtained and readings for blood pressure reflected between the 60s and 70s mmHg (millimeters of mercury) systolic (normal being greater than 90/60). PTA #1 stated he and COTA #1 placed Resident #1 back in a supine position in bed and left the room to locate Nurse #1. PTA #1 stated Resident #1 was fidgety and agitated during the therapy treatment but did not recall any behaviors such as hollering out while he was in her room. PTA #1 stated he approached Nurse #1 who was at her medication cart in the hallway and alerted her that Resident #1's blood pressure readings had been low, stated what they were, and she had increase confusion, not acting like herself, and was unable to participate in therapy. PTA #1 stated Nurse #1 replied to him that Resident #1's blood pressure was normally low at baseline and did not appear concerned with reports by him. PTA #1 stated Nurse #1 never told him that she would assess Resident #1 and evaluate his concerns of the change of condition. PTA #1 stated he left the nurse at the medication cart and proceeded towards the therapy room. When he passed the MDS Nurse Coordinator's office, he entered the office and requested the nurse to review Resident #1's previous blood pressures and alerted her of the low blood pressure readings that he and COTA #1 had obtained. PTA #1 stated the MDS Nurse noted the blood pressures obtained by the PTA #1 and COTA #1 were lower than Resident #1's baseline. PTA #1 stated the MDS Nurse contacted the Staff Development Coordinator (SDC) Nurse via phone who said she was leaving for the day but would go and recheck Resident #1's blood pressure. An interview with COTA #1 on 11/20/23 at 12:30 PM revealed he was alerted on 11/7/23 in the afternoon (he could not recall exact time) by PTA #1 that he was concerned that Resident #1 was not her normal self. COTA #1 stated he entered Resident #1's room with PTA #1 and recognized Resident #1 appeared drowsy, confused, and agitated. He said while he and PTA #1 were in the room the hall nurse (Nurse #1) entered the room with the resident's medications and attempted to administer them, but Resident #1 spit them all out on her clothes. COTA #1 stated while Nurse #1 was in the room, PTA #1 mentioned to Nurse #1 that Resident #1 did not seem to be at her baseline, but Nurse #1 did not acknowledge the statement, but instead quickly retrieved the medications Resident #1 spit out and left the room. COTA #1 indicated he and PTA #1 continued to attempt to get Resident #1 to participate without success then decided to obtain vital [TRUNCATED]