**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff, and Medical Director (MD) interviews the facility failed to protect a Resident's right to be free from neglect when Resident # 280 experienced a medical emergency and emergency medical services (EMS) were not provided. The resident was only responsive to painful stimuli on [DATE] around 5:00 PM and 911 was not initiated until 8:10 PM. Resident #280 was transferred to the hospital and diagnosed with metabolic encephalopathy (a problem in the brain caused by a chemical imbalance) due to urinary tract infection (UTI) and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. On [DATE] Resident #280 was discharged to hospice care for comfort care. On [DATE] Resident #280 expired. This occurred for 1 of 3 residents reviewed for neglect. Immediate jeopardy began on [DATE] when EMS was not initiated for a medical emergency. Immediate jeopardy was removed on [DATE] 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 with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: 1. Resident #280 was admitted to the facility on [DATE] with diagnoses which included a fracture of the upper and lower end of the right fibula (bone in the lower leg), type 2 diabetes, atrial fibrillation (irregular heart rate), and heart disease. Resident #280 was not receiving hospice services. A review of the care plan dated [DATE] revealed Resident #280 was at risk for hypoglycemia with a goal to be free of signs and symptoms of hypoglycemia. Interventions included for nursing staff to assess blood sugars as per order and as needed for symptoms of hypoglycemia/hyperglycemia. The care plan further revealed Resident #280 was at risk for altered cardiac and respiratory status with a goal that Resident #280 would not have a preventable crisis. Interventions included for nursing staff to monitor oxygen saturations as needed, to monitor for signs and symptoms of decreased cardiac output (rapid, slow, weak, or diminished pulse, hypotension, hypertension, dizziness, syncope, dyspnea, chest pain, restlessness, cyanosis, alerted mental status, congestion, or shortness of breath). An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #280 was cognitively intact and had not exhibited any behaviors. She was not documented as being on hospice services or receiving insulin. A review of the on-call physician correspondence initiated by Nurse #1 on [DATE] at 5:30 pm as stated by Nurse #1 revealed Resident #280 was lethargic, barely arousable, even with sternal rub. Also, that staff states she was very 'sleepy' today. Nurse Practitioner #2 had advised Nurse #1 to send Resident #280 to the emergency room at 6:43 pm. Nurse Practitioner #2 was unable to be interviewed. An interview was conducted on [DATE] at 10:41 am with Nurse #1. Nurse #1 reported she worked first shift (6:30 am to 6:30 pm) and usually floated between halls. She reported on [DATE] she floated to 200-hall (Resident #280's hall) at 2:30 pm and relieved Nurse #2. Nurse #2 informed Nurse #1 that Resident #280 had been sleepy all day. Nurse #1 stated after she finished report she took time to get adjusted and started passing medications. She reported she did not go check on Resident #280 until 5:00 pm, at which time the resident was only responsive to painful stimuli. Nurse #1 reported she obtained vital signs after she realized Resident #280 was only responsive to painful stimuli and stated she had not checked her blood sugar. She reported she consulted their on-call telehealth provider around 6:00 pm. Nurse #1 reported the on-call provider had advised her to send Resident #280 to the emergency room around 6:30 pm. She reported she then gave the report to Paramedic #1, printed off Resident #280's information for EMS, and left for the day. She reported she had not notified Resident #280's family or called EMS because she was under the assumption that Paramedic #1 would. Nurse #1 stated she gave shift report to Paramedic #1 (employed by the facility and functioning as a nurse) on [DATE] at 6:30 pm when Paramedic #1 started his shift. Nurse #1 stated she felt as though she had neglected Resident #280 because she should have not relied on Paramedic #1 to initiate EMS and complete her work. Vital signs were entered on [DATE] at 6:41 pm (which were obtained at 5:30 pm by Nurse #1 per her report). Resident #280's blood pressure was 106/60, heart rate was 62 beats per minute, respiration rate was 16 breaths per minute, oxygen saturation was 91% on room air, and her temperature was 96.5 degrees Fahrenheit axillary (under the arm). Further review of Resident #280's medical record revealed no ongoing assessment, vital signs, or blood glucose monitoring from 5:30 pm until she was transferred by EMS at 8:13 pm. A review of a nursing note completed by Paramedic #1 (employed by the facility) on [DATE] at 9:19 pm revealed Resident #280 had a change in condition in the last 24 hours and he was told in shift change report that Resident #280 was only responsive to painful stimuli. He documented he had called EMS at 8:00 pm to see where they were and was told by EMS that they had never been contacted, he then requested an ambulance and sent Resident #280 to the Emergency Room. A telephone interview was conducted on [DATE] at 11:02 am with Paramedic #1. Paramedic #1 reported he was not able to remember the events involving Resident #280 on [DATE]. He stated he would have documented any assessment, monitoring, vital signs, and/or interventions in his nursing note. A follow-up telephone interview was conducted on [DATE] at 4:09 pm with Paramedic #1. Paramedic #1 reported he started his shift at 6:30 pm on [DATE] and received report from Nurse #1. Paramedic #1 stated Nurse #1 reported Resident #280 was only responsive to a sternal rub. Paramedic #1 reported Nurse #1 had contacted the on-call provider, had received orders from the on-call provider to send Resident #280 to the Emergency Room, and asked him to check on Resident #280 while she gathered the paperwork for transfer. Paramedic #1 reported he assessed Resident #280 at 6:30 pm, at which time Resident #280 was able to communicate verbally. Paramedic #1 stated he assessed Resident #280's heart sounds, lung sounds, and pulses however he had not reassessed Resident #280's vital signs because she appeared stable. Paramedic #1 reported he was under the impression Nurse #1 had called EMS. Paramedic #1 reported he started his medication pass and checked the hall to see if an EMS stretcher was in the hall. Paramedic #1 reported he called to check the status of EMS at 8:00 pm at which time he was told EMS had never been notified. Paramedic #1 stated at that time he requested an ambulance, which arrived shortly after, and transferred Resident #280 out of the facility. He reported he failed to document his assessments because he had forgotten. Paramedic #1 stated Nurse #1 should have initiated EMS prior to leaving the facility. He did not speak to the incident as neglect. A telephone interview was conducted on [DATE] at 10:57 am with EMS Personnel at dispatch. The EMS Personnel reported a facility staff member had called to initiate EMS services on [DATE] at 8:10 pm and an EMS unit arrived on scene at 8:13 pm. Review of the Emergency Medical Services (EMS) assessment dated [DATE] at 9:03 pm revealed Resident #280 was found to be unresponsive and hypoglycemic, with a blood sugar of 74 mg/dL, and was transferred out of the facility at 8:13 pm to the Emergency Room. A review of the emergency room Physician note dated [DATE] at 3:32 am revealed Resident #280 had arrived at the emergency room on [DATE] with altered mental status. The facility had reported to EMS that Resident #280 was normally awake however she was much more somnolent and not able to swallow her pills. The emergency room Physician documented Resident #280 was unable to participate in a neurological exam, remained obtunded, and was not able to follow any commands. EMS had furthered reported to the emergency room Physician Resident #280's blood sugar was 74 and she had likely not been eating or drinking all day. Documentation further revealed Resident #280 was admitted with a primary diagnosis of metabolic encephalopathy due to urinary tract infection (UTI) and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. A review of the hospital physician Discharge summary dated [DATE] revealed Resident #280 had continued to decline. A discussion was had with Resident #280's Representative to keep her comfortable and a Do Not Resuscitate (DNR) order was implemented. Resident #280 was then discharged to hospice. A review of the death certificate revealed Resident #280 expired on [DATE] with the immediate cause of End of Life Comfort Measures with Hospice Care. An interview was conducted on [DATE] at 6:00 pm with the Director of Nursing (DON). The DON reported Resident #280 was found unresponsive and with stable vital signs on [DATE]. The DON reported Nurse #1 made an error by not initiating EMS and that Nurse #1 should have never left her shift without calling EMS. The DON stated Nurse #1 and Paramedic #1 should have performed head-to-toe assessments, ongoing assessments, and ongoing vital signs (including blood sugars). The DON reported she had not felt as though Nurse #1 or Paramedic #1 neglected Resident #280. An interview was conducted on [DATE] at 6:08 pm with the Administrator. The Administrator reported he had not been made aware of the events leading up to Resident #280 being transferred to the hospital on [DATE] until the DON informed him on [DATE]. He reported Nurse #1 should not have left the building without initiating EMS for Resident #280 and that there was a huge delay in care. He reported he was not aware that Nurse #1 had not performed a head-to-toe assessment, ongoing assessment, and ongoing vital signs (including blood sugar checks). The Administrator reported he had not felt as though Nurse #1 or Paramedic #1 neglected Resident #280. An interview was conducted on [DATE] at 1:22 pm with the MD. The MD reported he had assessed Resident #280 on the morning of [DATE] and reported Resident #280 was alert at that time. The MD stated he was not aware of the delay in initiating EMS and the lack of monitoring until today ([DATE]) and reported Resident #280 should have been monitored until she was transferred to the hospital. The Administrator was notified of Immediate Jeopardy on [DATE] at 6:08 pm. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Nurse #1 reported she was notified during report from Nurse #2 at 2:30 pm that Resident #280 had been excessively sleepy that morning ([DATE]). Nurse #1 reported she had not assessed Resident #280 until 5:00 pm, at which time she was only responsive to painful stimuli. Nurse #1 contacted the on-call Medical Service to have Resident #280 assessed at 6:00 pm and was advised at 6:30 pm to transfer her to the hospital. Nurse #1 only checked Resident #280's vital sings once, did not obtain oxygen saturations or blood sugar and did not activate 911 when resident was found to be unresponsive at 5 pm. Nurse #1 stated she printed out the medical record after she had given report to Paramedic #1. Nurse #1 reported she was under the assumption that Paramedic #1 would contact Emergency Medical Services (EMS). Paramedic #1 completed walking rounds of his assigned unit on [DATE] at 8:00 pm and realized that Resident #280 had not be transported to the hospital and contacted EMS at 8:10 pm, at what time he was informed that EMS was never called for transport. EMS arrived on [DATE] at 8:13 pm and transported Resident #280 to the hospital where she was diagnosed with acute metabolic encephalopathy related to sepsis from urinary tract infection versus bacteremia from wounds, dehydration, and hypoglycemia. Resident #280 was transferred to hospital on [DATE] and did not return to the facility. On [DATE] the Regional Director of Clinical Services educated Nurse #1 and Paramedic #1 on effective communication between staff during a Medical Emergency, timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic. On [DATE] the Director of Nursing or Designee immediately audited the Situation, Background, Assessment and Recommendation and progress notes of residents sent to hospital in the last 30 days to confirm that no delay in assessment, monitoring or transfer to hospital occurred. No negative findings were found. On [DATE] the Director of Nursing or Designee audited Nursing progress notes from the last 72 hours to ensure no change of conditions were found and not followed up on in a timely manner. No negative findings were found. On [DATE] the Social Worker/Administrator or Designee interviewed residents with a BIMS of 12 or above regarding if they have had a change of condition that was not followed up on immediately, if they had any concerns of neglect and if they felt they had a delay in treatment. No negative findings were noted. The Director of Nursing or Designee audited Nursing progress notes from the last 72 hours of residents with a BIMS of less than 12 to ensure residents had no change of condition that was not followed up on immediately. No negative findings were noted. Specify the action of the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] the Director of Nursing or Designee interviewed all nursing and therapy staff regarding knowledge of any residents having change of conditions in the last 72 hours that were not addressed and if they were aware of any resident neglect. No negative findings were noted. On [DATE] the Director of Nursing or Designee educated all staff on reporting any change of condition to the nurse immediately. The Staff that were not working on [DATE] will be educated prior to start of their next shift. On [DATE] the Director of Nursing or Designee educated all staff on effective communication between staff members during a Medical Emergency. The Staff that were not working on [DATE] will be educated prior to start of their next shift. On [DATE] the Director of Nursing or Designee educated all Licensed Nurses and Paramedics on observing and assessing residents for change of condition from baseline and communicating to provider for follow up and treatment in a timely manner. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to the start of their next shift. On [DATE] the Director of Nursing or Designee educated all Licensed Nurses and Paramedics on recognizing serious decline of cognition and responsiveness of resident as an emergent occurrence and to contact provider and transfer to hospital immediately. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to the start of their next shift. On [DATE] the Director of Nursing or Designee educated Licensed Nurses and Paramedics on timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic and the Abuse and Neglect Policy. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to the start of their next shift. On [DATE] the Director of Nursing or Designee educated all staff on the Abuse and Neglect Policy. The Staff that were not working on [DATE] will be educated prior to start of their next shift. On [DATE] Ad Hoc QAPI was completed regarding Abuse and Neglect. In addition, effective communication between staff in Medical Emergencies, timeliness of assessment and monitoring of change of conditions to include transferring resident to hospital. On [DATE] the Regional Director of Clinical Services educated the Administrator, Director of Nursing, Assistant Director of Nursing, Scheduler and Human Resources on the Orientation Process that will include education on recognizing change of condition, effective communication during a Medical Emergency, timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic. The Director of Nursing or Designee will ensure newly hired Licensed Nurses or Paramedics receive education on the Effective Communication during a Medical Emergency, Abuse and Neglect Policy and timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic in Orientation. The Director of Nursing or Designee will ensure Agency Staff receive education on Effective Communication during a Medical Emergency, the Abuse and Neglect Policy and timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic prior to first shift of working in facility. Immediate jeopardy removal date: [DATE] The credible allegation was validated [DATE] onsite. Staff interviews revealed that NAs, Medication Technicians, and Nurses had received in-service education regarding abuse and neglect which included how to keep the residents safe, reporting the issue to the immediate supervisor, reporting change in condition, and effective communication among staff. Nursing staff also received specific education related to neglect and how/who to report suspensions of neglect. A review of education revealed staff had received neglect training. The immediate jeopardy removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #18 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, coronary artery disease, and hypertension. Physician records and active physician orders revealed she also had a diagnosis of edema (swelling in the extremities). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact and coded as receiving diuretic medication (a medication that helps remove excess fluid from the body). Review of Resident #18's active physician orders revealed an order dated [DATE] for Furosemide (diuretic) tablet 40 milligrams (mg) give one tablet by mouth two times a day for edema. Review of Resident #18's electronic medication record (EMR) was completed on [DATE] and revealed Resident #18's weight had been monitored monthly by the facility. She had a weight documented on [DATE] of 254.6 pounds (lbs.) and on [DATE] she had a weight of 272 lbs. documented. The facility obtained a reweight weight on [DATE] that was recorded as 273.4 lbs. Resident #18 had a 7.38 % (18.8 lbs.) weight gain in a 30-day period. Review of the provider progress notes and nursing notes were reviewed from [DATE] through [DATE] and revealed no documentation that Resident #18 had been clinically assessed for her weight gain or increased edema. Review of the Registered Dietician's (RD) progress note date [DATE] stated Resident #18 had triggered for a significant weight gain since [DATE] and the weight gain had been confirmed with a reweight. Her note mentioned Resident #18 received diuretic medication. The RD note stated NP/ MD aware and that she would ask the Nurse Practitioner (NP)/ Medical Doctor (MD) to review Resident #18's antidepressant medications that could have an effect on her appetite. The RD note indicated a plan to continue to monitor Resident #18's intake, weights, and labs. Further review of Resident #18's medical record revealed there was no recent lab work or diagnostics completed to assess Resident #18's significant weight gain. There were no orders regarding more frequent weight monitoring, such as weekly weight monitoring to address Resident #18's significant weight gain. An interview and observation were conducted on [DATE] with Resident #18 at 3:45 PM. Resident #18 was observed laying on her bed with both of her feet elevated on a pillow. She complained of having increased edema in her lower legs. Observation of Resident #18's lower extremities, ankles, and feet revealed visible swelling was present. An interview was conducted on [DATE] at 9:10 AM with the RD. She stated she saw all residents who had significant weight gain. She stated she always asked for the staff to obtain a re-weigh weight to ensure the weight was not an erroneous weight and then she would address the weight gain. The RD stated Resident #18 was a good eater, was on a diuretic medication, and took an antidepressant medication that could stimulate appetite. The RD stated she had not spoken to the NP/ MD about Resident #18's weight gain. She stated she would have left a note for the NP/MD regarding Resident #18's gain in her recommendations that would have been given to the NP/ MD by the Quality Assurance (QA) nurse. She explained the QA nurse completed rounds with the NP/ MD and reviewed the RD recommendations with the NP/ MD during their routine facility visit. The RD stated she had not spoken to Resident #18 about her weight gain or seen Resident #18 in person. The RD explained the facility process for weight monitoring. She stated the Dietary Manager (DM) kept a log of all resident weights and printed the log weekly. She said the NP/ MD would be notified of weight changes weekly. She stated she would do a hard core look at the resident and then would give recommendations to the NP/MD about what needed to be addressed and the recommendations were reviewed by the NP/ MD during their next facility visit. She stated she would alert nursing if she saw an issue that needed to be addressed sooner by the NP/ MD. The RD stated she alerted the QA nurse about Resident #18's significant weight gain. The RD stated she was able to order labs if a resident needed them. She stated labs possibly could have been indicated for Resident #18. She explained she typically ordered a complete metabolic panel (CMP) for residents who had weight gain to check renal function, sodium levels, protein levels. The RD stated weekly, or daily weight monitoring was indicated for residents with heart failure or fluid gains. The RD stated a no added salt (NAS) diet would be indicated for residents who had heart failure or a cardiac history. The RD stated a NAS diet would be indicated for a resident who received diuretic medication and had a history of edema. She said Resident #18 could possibly benefit from a NAS diet. An interview was completed on [DATE] at 9:44 AM with Nurse #2. She stated she was not aware of Resident #18's weight gain. She said she was not aware that Resident #18 had increased edema. She verbalized she had not assessed Resident #18 for edema because she had not been aware of her weight gain. An interview was conducted on [DATE] at 9:14 AM with the DM. She stated resident weight monitoring was a group effort. She stated she kept a log of all the residents' weights and tried to keep an eye on the resident weights to monitor for changes. The DM stated the RD reviewed resident weights when she was at the facility weekly. She said the RD would make recommendations when she reviewed a resident's weights and if she felt like they needed to be changed to more frequent weight monitoring or different diet the RD would do it. The DM stated after facility monthly weights were completed, she and the RD initially looked at the weights and would make a reweigh list of residents who needed to be reweighed. She explained residents who would need to be reweighed were residents who triggered for a significant weight gain or loss of 5% in 30 days. The DM explained the facility held a weekly interdisciplinary team (IDT) meeting on Fridays. She said the Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator, QA nurse, and MDS nurses attended the IDT meeting weekly. The DM stated resident weight gain or loss was discussed during the IDT meeting weekly. The DM stated she printed the weight log weekly and gave a copy of the log to the QA nurse to review significant weight changes weekly with the NP/ MD during their facility visit. The DM stated if a resident received diuretic medication and had a large weight gain of 18 lbs. in 30 days, she would immediately notify the RD and have the RD assess and review the resident. She said if a resident was noticed to have a large weight gain before the IDT meeting, she would bring it to the QA nurses' attention so she could notify the NP/MD. She stated Resident #18's weight gain would have been discussed during the IDT meeting on [DATE]. An interview was completed on [DATE] at 10:15 AM with Nurse #8. She stated when weights were obtained the nurse entered the resident's weight into the residents EMR. Nurse #8 said she had not been aware of Resident #18's weight gain or increased edema. She said she had not assessed her for edema because she had not been aware of her weight gain. Nurse #8 stated if a resident was on a diuretic medication and had a weight gain of 18 lbs. in a month, she would be really worried. She said she had not contacted the NP/MD. An interview was performed on [DATE] at 2:02 PM with the QA nurse. She stated weights were reviewed during the IDT meetings on Fridays. She stated the DM would give her a copy of the weight log. She stated she usually gave the NP/MD the weight log sheet for them to look over when they were at the facility and then the NP/MD would give verbal orders addressing weight loss/ gain. She stated she had not specifically reviewed the weights with the NP/MD or discuss the residents who had weight loss/ gain. She stated she did not remember talking to the NP/MD about Resident #18's significant weight gain. The QA nurse stated she remembered discussing Resident #18's significant weight gain during the IDT meeting. She did not say what day Resident #18's weight gain had been discussed in the IDT meeting. She stated she had not contacted the NP/ MD before [DATE] about Resident #18's edema or weight gain. She stated if a resident had a significant weight gain the resident should be assessed by the NP/ MD and generally the NP/ MD would check labs or would increase the resident's diuretic medication. She said a resident would be changed to daily or weekly weight monitoring if weight gain was related to fluid. She stated Resident #18 had complained to her of edema on [DATE] and that she had notified the NP the next day on [DATE] that Resident #18 needed to be seen. The QA nurse did not mention that she had assessed Resident #18 on [DATE] or informed any of the floor nurses. The QA nurse stated, I guess I somehow or another dropped the ball on letting the NP know that the resident (Resident #18) needed to be seen. The QA nurse stated Resident #18 should have been clinically assessed and seen by the NP/MD sooner than [DATE] for her significant weight gain. An interview was performed on [DATE] at 3:11 pm with the DON. She stated Resident #18's weight gain should have been discussed in the morning clinical meeting and then weekly IDT meeting. She stated the IDT meeting focus with weights was weight loss because that was worse, but gain needed to be monitored too. She stated Resident #18 did not have heart failure but did have lots of edema. The DON stated it should be nursing who looked at residents with weight gain and edema to look at the clinical aspect for why the resident might be gaining weight. She stated Resident #18's weight gain should have been conveyed to the NP/ MD that week ([DATE]). She stated Resident #18 should probably be on weekly weight monitoring. An interview was completed on [DATE] at 10:31AM with the Administrator. He said clinically he did not know what happened in the incident and was not sure if the weight gain was because of Resident #18 retaining a lot of fluid. He stated in the IDT meeting he remembered Resident #18's weight gain being discussed. The Administrator stated Resident #18 should have been seen sooner by the NP/ MD to evaluate her clinically for things like diet change, lab work, edema, or the need for an increase in her diuretic medication. An interview was performed on [DATE] at 12:12 PM with the NP. She said she had not been notified about Resident #18's weight gain. She stated she had not realized Resident #18 had gained that much weight. The NP stated if she had been notified of Resident #18's weight gain at the beginning of April when the weight gain was noted by the facility, she would have assessed Resident #18. The NP stated she would have done a B-type natriuretic peptide (BNP) test (a test Providers use to diagnose and monitor heart failure) to check and make sure it was in range and fluid overload was not causing the weight gain. She stated this was what she would usually do if a resident had a weight gain of 3-5 lbs. in a week or a significant weight gain. The NP stated that Resident #18 had increased edema to both of her lower extremities when she saw her on [DATE]. The NP stated if a resident had large weight gains their weight should be monitored at least weekly for weight gains. Based on observations, record review and Resident, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews nursing staff failed to identify the seriousness of a change in condition for a resident with a diagnosis of insulin dependent diabetes and provide thorough ongoing monitoring and comprehensive assessments. On [DATE] at 2:30 PM Nurse #2 reported to Nurse #1 Resident #280 was sleepy all day. Nurse #1 did not assess Resident #280 until 5:00 PM and observed the resident was only responsive to painful stimuli and obtained a set of vital signs but did not check her blood sugar. The on-call provider was contacted, and Nurse #1 was instructed to transfer Resident #280 to the Emergency Room. Lack of effective communication between Nurse #1 and oncoming Paramedic #1 (employed by the facility and functioning as a nurse) resulted in Emergency Medical Services (EMS) not being contacted until 8:10 PM. Resident #280 was unresponsive with a blood sugar of 74 and was transferred to the Emergency Room. Resident #280 was admitted to the hospital with a primary diagnosis of metabolic encephalopathy (brain dysfunction), was transferred to hospice on [DATE], and expired on [DATE]. Resident #282 was admitted on [DATE] and the facility failed to administer sliding scale insulin (insulin dose based on predefined blood sugar ranges) per the hospital discharge summary or monitor blood sugar levels per the physician orders for a resident with a diagnosis of insulin dependent diabetes. On [DATE] Resident #282 reported extreme thirst and requested for her blood sugar to be checked. Resident #282's blood sugar was 548 (normal range 80 to 130) and a blood sugar greater than 300 could indicate diabetic ketoacidosis which is a dangerous and life-threatening complication of diabetes that occurs when your body does not get enough insulin.) The facility failed to assess a resident for the cause of significant weight gain and edema (swelling caused by too much fluid trapped in the body's tissues) (Resident #18). The deficient practice occurred for 3 of 3 sampled residents (Residents #280, #282 and #18). Immediate jeopardy for Resident #280 began on [DATE] when nurses failed to identify and effectively respond to a medical emergency. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. Immediate jeopardy for Resident #282 began on [DATE] when the facility failed to administer sliding scale insulin or monitor blood sugar levels. Immediate Jeopardy was removed on [DATE] 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 with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Example #3 was cited at t lower scope and severity of D. The findings included: 1. Resident #280 was admitted to the facility on [DATE] with diagnoses which included a fracture of the upper and lower end of the right fibula (bone in the lower leg), type 2 diabetes, atrial fibrillation (irregular heart rate), and heart disease. Resident #280 was not receiving hospice services. A review of Resident #280's physicians orders from [DATE] through [DATE] revealed the following: A standing order dated [DATE] through [DATE] for blood glucose levels to be checked in the morning and at night for the first 4 days and to inform MD of results. Review of Resident #280's physician orders and documentation from [DATE] through [DATE] revealed no further orders for blood sugars to be checked and no notification was made to the MD regarding blood sugars. The Medication Administration Record (MAR) for January revealed the following blood sugars: [DATE] at 9:44 pm Resident #280's blood sugar was 175 mg/dL. [DATE] at 5:17 am Resident #280's blood sugar was 137 mg/dL. [DATE] at 4:45 pm Resident #280's blood sugar was 166 mg/dL. [DATE] at 5:06 pm Resident #280's blood sugar was 158 mg/dL. [DATE] at 6:21 am Resident #280's blood sugar was 136 mg/dL. [DATE] at 4:46 pm Resident #280's blood sugar was 164 mg/dL. [DATE] at 6:10 am Resident #280's blood sugar was 135 mg/dL. An order dated [DATE] through [DATE] for Insulin Glargine (long-acting insulin) Subcutaneous Solution 16 units to be injected subcutaneously (under the skin) at bedtime for type 2 diabetes. A review of Resident #280's Medication Administration Record (MAR) from [DATE] to [DATE] revealed initialed administrations for Insulin Glargine 16 units subcutaneously daily. A review of the care plan dated [DATE] revealed Resident #280 was at risk for hypoglycemia with a goal to be free of signs and symptoms of hypoglycemia. Interventions included for nursing staff to assess blood sugars as per order and as needed for symptoms of hypoglycemia/hyperglycemia. The care plan further revealed Resident #280 was at risk for altered cardiac and respiratory status with a goal that Resident #280 would not have a preventable crisis. Interventions included for nursing staff to monitor oxygen saturations as needed, to monitor for signs and symptoms of decreased cardiac output (rapid, slow, weak, or diminished pulse, hypotension, hypertension, dizziness, syncope, dyspnea, chest pain, restlessness, cyanosis, alerted mental status, congestion, or shortness of breath). A review of Resident #280's blood sugar summary revealed the last blood sugar obtained was on [DATE] and was 135 milligrams per deciliter (mg/dL) at that time. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #280 was cognitively intact and had not exhibited any behaviors. She was not documented as being on hospice services or receiving insulin. A review of the breakfast meal intake documented by Nurse Aide (NA #1) revealed Resident #280 ate 51-75% on [DATE]. Vital signs were obtained on [DATE] at 12:12 pm by Nurse #2. Resident #280's blood pressure was 116/64, heart rate was 64 beats per minute, respiration rate was 16 breaths per minute, oxygen saturation was 92% via nasal canula at an unknown rate, and her temperature was 97.6 degrees Fahrenheit. An interview was conducted on [DATE] at 11:47 am with Nurse #2. Nurse #2 reported she worked from 6:30 am to 2:30 pm on [DATE] with Resident #280. She reported she vaguely remembered Resident #280 but recalled her being sleepy. She reported she had not thought it was unusual because she had not worked with Resident #280 often. Nurse #2 reported she did not perform or document a head-to-toe assessment on Resident #280 but had obtained vital signs on [DATE] at 12:12 pm and reported her vital signs were stable. An attempt was made to interview Nurse Aide (NA) #1 on [DATE] who worked first shift (6:30 am to 2:30 pm) on [DATE]. NA#1 was unable to recall Resident #280. A review of the lunch intake documented by NA #1 revealed Resident #280 ate 76-100% of her meal on [DATE]. A review of the on-call physician correspondence initiated by Nurse #1 on [DATE] at 5:30 pm as stated by Nurse #1 revealed Resident #280 was lethargic, barely arousable, even with sternal rub. Also, that staff states she was very 'sleepy' today. Nurse Practitioner #2 had advised Nurse #1 to send Resident #280 to the emergency room at 6:43 pm. Nurse Practitioner #2 was unable to be interviewed. An interview was conducted on [DATE] at 10:41 am with Nurse #1. Nurse #1 reported she worked first shift (6:30 am to 6:30 pm) and usually floated between halls. She reported on [DATE] she floated to 200-hall (Resident #280's hall) at 2:30 pm and relieved Nurse #2. Nurse #2 informed Nurse #1 that Resident #280 had been sleepy all day. Nurse #1 stated after she finished report she took time to get adjusted and started passing medications. She reported she did not go check on Resident #280 until 5:00 pm, at which time the resident was only responsive to painful stimuli. Nurse #1 reported she obtained vital signs after she realized Resident #280 was only responsive to painful stimuli and stated she had not checked her blood sugar. She reported she consulted their on-call telehealth provider around 6:00 pm. Nurse #1 reported the on-call provider had advised her to send Resident #280 to the emergency room around 6:30 pm. She reported she then gave the report to Paramedic #1, printed off Resident #280's information for EMS, and left for the day. She reported she had not notified Resident #280's family or called EMS because she was under the assumption that Paramedic #1 would. Nurse #1 stated she gave shift report to Paramedic #1 (employed by the facility and functioning as a nurse) on [DATE] at 6:30 pm when Paramedic #1 started his shift. A review of the dinner intake for Resident #280 revealed no recorded on [DATE]. Vital signs were entered on [DATE] at 6:41 pm (which were obtained at 5:30 pm by Nurse #1 per her report). Resident #280's blood pressure was 106/60, heart rate was 62 beats per minute, respiration rate was 16 breaths per minute, oxygen saturation was 91% on room air, and her temperature was 96.5 degrees Fahrenheit axillary (under the arm). Further review of Resident #280's medical record revealed no ongoing assessment, vital signs, or blood glucose monitoring from 5:30 pm until she was transferred by EMS at 8:13 pm. A review of a nursing note completed by Paramedic #1 (employed by the facility) on [DATE] at 9:19 pm revealed Resident #280 had a change in condition in the last 24 hours and he was told in shift change report that Resident #280 was only responsive to painful stimuli. He documented he had called EMS at 8:00 pm to see where they were and was told by EMS that they had never been contacted, he then requested an ambulance and sent Resident #280 to the Emergency Room. A telephone interview was conducted on [DATE] at 11:02 am with Paramedic #1. Paramedic #1 reported he was not able to remember the events involving Resident #280 on [DATE]. He stated he would have documented any assessment, monitoring, vital signs, and/or interventions in his nursing note. A follow-up telephone interview was conducted on [DATE] at 4:09 pm with Paramedic #1. Paramedic #1 reported he started his shift at 6:30 pm on [DATE] and received report from Nurse #1. Paramedic #1 stated Nurse #1 reported Resident #280 was only responsive to a sternal rub. Paramedic #1 reported Nurse #1 had contacted the on-call provider, had received orders from the on-call provider to send Resident #280 to the Emergency Room, and asked him to check on Resident #280 while she gathered the paperwork for transfer. Paramedic #1 reported he assessed Resident #280 at 6:30 pm, at which time Resident #280 was able to communicate verbally. Paramedic #1 stated he assessed Resident #280's heart sounds, lung sounds, and pulses however he had not reassessed Resident #280's vital signs because she appeared stable. Paramedic #1 reported he was under the impression Nurse #1 had called EMS. Paramedic #1 reported he started his medication pass and checked the hall to see if an EMS stretcher was in the hall. Paramedic #1 reported he called to check the status of EMS at 8:00 pm at which time he was told EMS had never been notified. Paramedic #1 stated at that time he requested an ambulance, which arrived shortly after, and transferred Resident #280 out of the facility. He reported he failed to document his assessments because he had forgotten. A telephone interview was conducted on [DATE] at 10:57 am with EMS Personnel at dispatch. The EMS Personnel reported a facility staff member had called to initiate EMS services on [DATE] at 8:10 pm and an EMS unit arrived on scene at 8:13 pm. Review of the Emergency Medical Services (EMS) assessment dated [DATE] at 9:03 pm revealed Resident #280 was found to be unresponsive and hypoglycemic, with a blood sugar of 74 mg/dL, and was transferred out of the facility at 8:13 pm to the Emergency Room. A review of the emergency room Physician note dated [DATE] at 3:32 am revealed Resident #280 had arrived at the emergency room on [DATE] with altered mental status. The facility had reported to EMS that Resident #280 was normally awake however she was much more somnolent and not able to swallow her pills. The emergency room Physician documented Resident #280 was unable to participate in a neurological exam, remained obtunded, and was not able to follow any commands. EMS had furthered reported to the emergency room Physician Resident #280's blood sugar was 74 and she had likely not been eating or drinking all day. Documentation further revealed Resident #280 was admitted with a primary diagnosis of metabolic encephalopathy due to urinary tract infection (UTI) and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. A review of the hospital physician Discharge summary dated [DATE] revealed Resident #280 had continued to decline. A discussion was had with Resident #280's Representative to keep her comfortable and a Do Not Resuscitate (DNR) order was implemented. Resident #280 was then discharged to hospice. A review of the death certificate revealed Resident #280 expired on [DATE] with the immediate cause of End of Life Comfort Measures with Hospice Care. An interview was conducted on [DATE] at 11:17 am with the Director of Nursing (DON). The DON reported Resident #280 was found unresponsive and with stable vital signs on [DATE]. She reported Nurse #1 contacted the on-call telehealth provider around 5:00 pm. The DON reported Paramedic #1 checked on Resident #280 around 8:00 pm while he was performing his walking rounds and realized that the ambulance had still not arrived to get the resident. A follow-up interview was conducted on [DATE] at 6:00 pm with the DON. The DON reported Nurse #1 should have never left her shift without calling EMS. An interview was conducted on [DATE] at 6:08 pm with the Administrator. The Administrator reported he had not been made aware of the events leading up to Resident #280 being transferred to the hospital on [DATE] until the DON informed him on [DATE]. He reported Nurse #1 should have not left the building without initiating EMS for Resident #280 and that there was a huge delay in notifying EMS. An interview was conducted on [DATE] at 1:22 pm with the MD. The MD reported he had assessed Resident #280 on the morning of [DATE] and reported Resident #280 was alert at that time. The MD stated he was not made aware of Resident #280's change in condition until after she had been admitted to the hospital. The MD stated he would expect facility staff to notify a provider if a resident had an acute change in mental status. He reported the resident would need to be evaluated and transferred to the hospital for further treatment and evaluation when there was an acute change in mental status to identify and treat the cause. The MD stated he was not aware of the delay in initiating EMS and the lack of monitoring until today ([DATE]). The Administrator was made aware of Immediate Jeopardy on [DATE] at 6:08 pm. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance: Nurse #1 reported she was notified during a report from Nurse #2 at 2:30 pm that Resident #280 had been excessively sleepy that morning ([DATE]). Nurse #1 reported she had not assessed Resident #280 until 5:00 pm, at which time she was only responsive to painful stimuli. Nurse #1 contacted the on-call Medical Service to have Resident #280 assessed at 6:00 pm and was advised at 6:30 pm to transfer her to the hospital. Nurse #1 only checked Resident #280's vital signs once, did not obtain oxygen saturations or blood sugar and did not activate 911 when resident was found to be unresponsive at 5 pm. Nurse #1 stated she printed out the medical record after she had given the report to Paramedic #1. Nurse #1 reported she was under the assumption that Paramedic #1 would contact Emergency Medical Services (EMS). Paramedic #1 completed walking rounds of his assigned unit on [DATE] at 8:00 pm and realized that Resident #280 had not been transported to the hospital and contacted EMS at 8:10 pm, at what time he was informed that EMS was never called for transport. EMS arrived on [DATE] at 8:13 pm and transported Resident #280 to the hospital where she was diagnosed with acute metabolic encephalopathy related to sepsis from urinary tract infection versus bacteremia from wounds, dehydration, and hypoglycemia. Resident #280 was transferred to hospital on [DATE] and did not return to the facility. On [DATE] the Regional Director of Clinical Services educated Nurse #1 and Paramedic #1 on effective communication between staff during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic. On [DATE] the Director of Nursing or Designee immediately audited the Situation, Background, Assessment and Recommendation and progress notes of residents sent to hospital in the last 30 days to confirm that no delay in assessment, monitoring or transfer to hospital occurred. No negative findings were found. On [DATE] the Director of Nursing or Designee audited Nursing progress notes from the last 72 hours to ensure no change of conditions were found and not followed up on in a timely manner. No negative findings were found. On [DATE] the Social Worker/Administrator or Designee interviewed residents with a BIMS of 12 or above regarding if they have had a change of condition that was not followed up on immediately and if they felt they had a delay in treatment. The Director of Nursing or Designee audited Nursing progress notes from the last 72 hours of residents with a BIMS of less than 12 to ensure residents had no change of condition that was not followed up on immediately. No negative findings were noted. On [DATE] the Director of Nursing or Designee interviewed all nursing and therapy staff regarding knowledge of any residents having change of conditions in the last 72 hours that were not addressed. No negative findings were noted. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] the Director of Nursing or Designee educated all Certified Nursing Assistants on reporting any change of condition of residents to the nurse immediately. The Director of Nursing or Designee will ensure Certified Nursing Assistants that were not working on [DATE] will be educated prior to their next shift. On [DATE] the Director of Nursing or Designee educated Licensed Nurses and Paramedics on timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temperature, Oxygen Saturation and Blood Sugar if resident is a Diabetic. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to their next shift. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to their next shift. On [DATE] Director of Nursing or Designee educated all staff on effective communication between staff members during a Medical Emergency. The staff that were not working on [DATE] will be trained prior to their next shift. The Director of Nursing or Designee will ensure all staff that were not working on [DATE] will be educated prior to their next shift. On [DATE] the Director of Nursing or Designee educated all Licensed Nurses and Paramedics on observing and assessing residents for change of condition from baseline and communicating to provider for follow up and treatment in a timely manner. The Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to their next shift. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working on [DATE] will be educated prior to their next shift. On [DATE] the Director of Nursing or Designee educated [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff and Medical Director (MD) interviews, the facility failed to ensure that facility staff (Nurse #1 and Paramedic #1) had completed Skills Competency's and required floor/unit orientation days with a preceptor prior to taking a resident assignment independently. On [DATE] at 2:30 pm, Nurse #2 informed Nurse #1 that Resident #280 had been excessively sleepy during her shift. Nurse #1 failed to assess Resident #280 until 5:00 pm, at which time Resident #280 was only responsive to painful stimuli. Nurse #1 was instructed at 6:30 pm to transfer Resident #280 to the hospital for evaluation and treatment. Nurse #1 failed to notify Emergency Medical Services (EMS) and was under the assumption that the oncoming staff member, Paramedic #1 (employed by the facility and functioning as a nurse), was going to notify EMS. Paramedic #1 failed to assess Resident #280 until 8:00 pm when he realized that EMS had not come to transfer the resident. Paramedic #1 called EMS at 8:10 pm and was told that EMS had not been contacted. Resident #280 was transferred to the hospital and later died. The deficient practice occurred for 2 of 5 facility staff members (Nurse #1 and Paramedic #1) reviewed for competency and had the high likelihood for causing the potential for serious harm to other residents. Immediate jeopardy began on [DATE] when the failure to verify Nurse #1 and Paramedic #1's competency and skills resulted in delayed treatment of Resident #280. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put into place are effective. The findings included: A review of Paramedic #1's job description, titled Paramedic for alternative practice setting, revealed duties which included providing direct nursing care to residents, assess resident's needs, develop individual care plan, administer nursing care, evaluate nursing care, and supervise nursing assistants and other personnel in the delivery of nursing care within his scope of practice. The job description further revealed that Paramedic #1 had not signed that he had reviewed his job description and agreed to abide by his job description during employment. Paramedic #1's job description was signed by the Director of Nursing (DON) on [DATE] and by the MD. A review of Paramedic #1's Orientation and Skills Competency Checklist dated [DATE] and was hired on [DATE] revealed he had not been checked off on the following: who to contact if needed supplies are not found, tube feeding, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, and correct tube placement. The Orientation and Skills Competency Checklists were signed as complete by Paramedic #1 on [DATE] and by the DON on [DATE]. The Orientation and Skills Competency Checklists revealed areas for the employee (Paramedic #1), DON, and Nurse preceptors to sign, however there was no space for the MD to sign as verification the Competency Checklist had been completed. An interview was conducted on [DATE] at 9:08 am with the SDC verified that Paramedic #1's Orientation and Skills Competency Checklist revealed he had not been checked off on who to contact if needed supplies are not found, tube feedings, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, correct tube placement, and the DON had signed verifying it was completed on [DATE]. She reported she was unsure why Paramedic #1's competency skills checks were not completed and that she had not noticed it. She verbalized all areas should have been checked off prior to Paramedic #1 taking a resident assignment independently . An interview was conducted on [DATE] at 9:25 am with the DON regarding Paramedic #1. The DON verified that Paramedic #1's Orientation and Skills Competency Checklist revealed he had not been checked off on who to contact if needed supplies are not found, tube feedings, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, correct tube placement, and she had signed verifying it was completed on [DATE]. She reported she was unsure why Paramedic #1's competency skills checks were not completed and that it must have been an oversight. She verbalized all areas should have been checked off prior to Paramedic #1 taking a resident assignment independently. A review of Nurse #1's Orientation and Skills Competency Checklist dated [DATE] and was hired on [DATE] revealed she had not been checked off on Pharmacy Services, Emergency box and/or Omnicell (medication dispensing machine), Emergency Medications, Diagnosis for Medication, Review of Required Assessments (paper or Electronic), Head to Toe Assessment and Documentation, Device List, Vital Signs, and had not completed her 4 required days of floor/unit training with a preceptor. The DON and Nurse #1 had signed the Checklist as complete. The Orientation and Skills Competency Checklists revealed areas for the employee (Nurse #1), DON, and Nurse preceptors to sign, however there was no space for the MD to sign as verification the Competency Checklist had been completed. An interview was conducted on [DATE] at 9:08 am with the Staff Development Coordinator (SDC) regarding Nurse #1. The SDC reported most of the facility staff orientation was completed by Human Resources. She reported as the SDC she educated facility staff about Personal Protective Equipment (PPE), handwashing, and administered their drug test. The SDC verbalized floor nursing staff completed skills competency check offs for newly hired employees during their required floor/unit training days. She stated after the Skills Competency Check List had been completed, the DON or her would review the competency and sign off to verify that the competencies had been completed. The SDC stated that precepting staff are required to date and sign/initial all skills areas of the competency sheet. She reported if a date or initials were missing next to a competency skill, it would be assumed that the staff member had not completed that competency check. She reported the DON would make the determination if a facility staff member could take a resident assignment independently without having completed all the competency skill check offs. The SDC verified that Nurse #1's Orientation and Skills Competency Checklist revealed she had not been checked off on Pharmacy Services, Emergency box and/or Omnicell, Stat Meds, Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs, had not completed her 4 required days of floor/unit training with a preceptor, and the DON had signed verifying it was completed on [DATE]. She reported she was unsure why Nurse #1's competency skills checks were not completed and that she had not noticed it. She verbalized all areas should have been checked off prior to Nurse #1 taking a resident assignment independently. An interview was conducted on [DATE] at 9:25 am with the DON regarding Nurse #1. The DON reported the SDC was responsible for ensuring staff had completed Competency Skills Checkoffs and the required floor/unit training days. She reported that competencies were required to be completed before a Nurse or Paramedic would have a resident assignment on their own. The DON verified that Nurse #1's Orientation and Skills Competency Checklist revealed she had not been checked off on Pharmacy Services, Emergency box and/or Omnicell, Emergency Medications, Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs, had not completed her 4 required days of floor/unit training with a preceptor, and that she had signed verifying it was completed on [DATE]. She reported that she did not notice there were missing competency skills checks on Nurse #1's form, and that she must have overlooked it. She reported the skills competency checks should have been completed prior to Nurse #1 taking a resident assignment independently. Resident #280 was admitted to the facility on [DATE] with diagnoses which included a fracture of the upper and lower end of the right fibula (bone in the lower leg), type 2 diabetes, atrial fibrillation (irregular heart rate), and heart disease. Resident #280 was not receiving hospice services. Resident #280's vital signs were entered on [DATE] at 6:41 pm (which were obtained at 5:30 pm per Nurse #1). Resident #280's blood pressure was 106/60, heart rate was 62 beats per minute, respiration rate was 16 breaths per minute, oxygen saturation was 91% on room air, and her temperature was 96.5 degrees Fahrenheit axillary (under the arm). A review of the on-call physician correspondence initiated by Nurse #1 on [DATE] at 5:30 pm as stated by Nurse #1 revealed Resident #280 was lethargic, barely arousable, even with sternal rub. Also, that staff states she was very 'sleepy' today. Nurse Practitioner #2 had advised Nurse #1 to send Resident #280 to the emergency room at 6:43 pm. Further review of Resident #280's medical record revealed no head-to-toe assessment, no ongoing assessment, vital signs, or blood glucose monitoring from 5:30 pm until she was transferred by EMS at 8:13 pm. A review of a nursing note completed by Paramedic #1(employed by the facility employed by the facility and functioning as a nurse) the last 24 hours and he was told in report that Resident #280 was only responsive to painful stimuli. He documented he had called EMS at 8:00 pm to see where they were and was told by EMS that they had never been contacted, he then requested an ambulance and sent Resident #280 to the Emergency Room. A telephone interview was conducted on [DATE] at 10:57 am with EMS Personnel at dispatch. The EMS Personnel reported a facility staff member had called to initiate EMS services on [DATE] at 8:10 pm and an EMS unit arrived on scene at 8:13 pm. Review of the Emergency Medical Services (EMS) assessment dated [DATE] at 9:03 pm revealed Resident #280 was found to be unresponsive and hypoglycemic, with a blood sugar of 74 mg/dL, and was transferred out of the facility at 8:13 pm to the Emergency Room. A review of the emergency room Physician note dated [DATE] at 3:32 am revealed Resident #280 had arrived at the emergency room on [DATE] with altered mental status. The facility had reported to EMS that Resident #280 was normally awake however she was much more somnolent and not able to swallow her pills. The emergency room Physician documented Resident #280 was unable to participate in a neurological exam, remained obtunded, and was not able to follow any commands. EMS had furthered reported to the emergency room Physician Resident #280's blood sugar was 74 and she had likely not been eating or drinking all day. Documentation further revealed Resident #280 was admitted with a primary diagnosis of metabolic encephalopathy due to urinary tract infection (UTI) and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. A review of the hospital physician Discharge summary dated [DATE] revealed Resident #280 had continued to decline. A discussion was had with Resident #280's Representative to keep her comfortable and a Do Not Resuscitate (DNR) order was implemented. Resident #280 was then discharged to hospice. A review of the death certificate revealed Resident #280 expired on [DATE] with the immediate cause of End of Life Comfort Measures with Hospice Care. A telephone interview was conducted on [DATE] at 1:12 pm with Nurse #1. Nurse #1 reported she had received training for Pharmacy Services, Emergency box and/or Omnicell (medication dispensing machine), Emergency Medications, Diagnosis for Medication, Review of Required Assessments (paper or Electronic), Head to Toe Assessment and Documentation, Device List, and Vital Signs. She reported she was not aware those skills had not been checked and initialed on the Orientation and Skills Competency Checklist. Nurse #1 reported she received at least five days of training and had spent each shift on a different hall with a different preceptor. Nurse #1 was not able to explain why the orientation days were not reflected on the Orientation and Skills Competency Checklist. She reported she was not able to recall if Resident #280 was a diabetic, but she voiced she would have referred to the Electronic Health Record (EHR). A telephone interview was conducted on [DATE] at 4:09 pm with Paramedic #1. Paramedic #1 reported he had not received much of an orientation and from what he was able to recall it was approximately three days long. He reported during those three days he was partnered with a seasoned nurse at the facility, shown how to use the computer system, which assessments to complete, and information about the facility/residents. Paramedic #1 reported since he had learned the computer charting quickly, the nurse preceptor had recommended he be released to start on his own. Paramedic #1 reported he was aware there were areas of his Competency Skills Checkoffs that were not completed, but he thought the areas missing were administrative sections that had not pertained to his role. He was unaware who to contact if needed supplies are not found, tube feedings, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, and correct tube placement had not been checked off. An interview was conducted on [DATE] at 10:45 am with the Administrator. The Administrator was not aware Nurse #1 and Paramedic #1 had not completed their Skills Competency Checkoffs and did not know why they had not been completed. An interview was conducted on [DATE] at 1:22 pm with the MD. The MD reported he was aware that Paramedics worked in the facility and performed nursing tasks. He reported that he would have wanted Paramedics and Nurses to have completed competency skills checks prior to taking a resident assignment independently and practicing under his license. He reported that he was unaware that Nurse #1 had not completed her competency skills check offs and required orientation days and he reported he was also unaware Paramedic #1 had not completed his competency skills check offs. Paramedic #1 signed the Orientation and Skills Competency Checklists on [DATE]. The Administrator was notified of Immediate Jeopardy on [DATE] at 10:50 am. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to ensure that Nurse #1 and Paramedic #1 had completed Orientation and Skills Competency Checklists prior to taking a resident assignment/medication cart. Review of Nurse #1's Orientation and Skills Competency Checklist, signed by the Director of Nursing (DON) as complete on [DATE], revealed Nurse #1 had not been signed off on Pharmacy Services, emergency medication back up kit and or electronic medication dispenser (Omni Cell), Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs, and had not completed her 4 required days of floor/unit training with a preceptor. Review of Paramedic #1's Orientation and Skills Competency Checklist, signed by the DON as complete on [DATE], revealed Paramedic#1 had not been signed off for the following: who to contact if needed supplies are not found, tube feeding, demonstrating knowledge and skill in the use of the resident individualizing plan of care for providing resident centered care and updating the plan of care as needed, demonstrating knowledge and skill in identifying, investigating, reporting, notifications, and follow up evaluations of change in resident conditions, demonstrating knowledge and understanding of facility quality improvement initiatives (QAPI), survey process, and checking for proper tube placement prior to each use per policy. On [DATE] Nurse #1 will complete the required days of floor/unit training with a preceptor prior to her next shift assigned to work. The Director of Nursing or Designee will sign off competencies for Nurse #1 on the Pharmacy Services, use of emergency medication back up kit, and or electronic medication dispenser (Omni Cell), Stat Meds, Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs prior to next shift assigned to work. Paramedic #1 was working his two weeks' notice and the Director of Nursing released him on [DATE] before his two-week notice expired. On [DATE] The Director of Nursing or Designee audited the employee files of licensed staff and Paramedics to ensure orientation and skills competency checklist were completed, any negative findings will be corrected immediately, and staff placed back into orientation or skills check off completed for any area missed during orientation. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] the Regional Director of Clinical Services educated the Director of Nursing, Assistant Director of Nursing, Administrator, Scheduler and Human Resources on the orientation process to include the required days of floor/unit training with a preceptor and completion of the skills competency checklist. On [DATE] the Director of Nursing or Designee will ensure all newly hired licensed staff have completed the required days of floor/unit training with a preceptor prior to being given an assignment. On [DATE] the Assistant Director of Nursing or Designee will complete the skill competency checklist for all newly hired licensed staff and Paramedics. The Director of Nursing or Designee will ensure all newly hired licensed staff and Paramedics have completed skills competency checklist prior to being given an assignment. On [DATE] Ad Hoc QAPI was completed related to following orientation policy and ensuring the skill checklist is completed for licensed staff and Paramedics prior to taking their first assignment. Alleged Date Immediate Jeopardy removal: [DATE] On [DATE], the facility's plan for Immediate Jeopardy removal effective [DATE] was validated by the following: documentation and interviews with staff. Review of the in-service sign in sheets revealed the Scheduler, DON, Assistant Director of Nursing (ADON)/SDC, Human Resources (HR), and Administrator received education regarding the orientation process, completion of the required number of floor/orientation days with a preceptor, and the importance of ensuring that all skills competency checks were completed for facility staff members prior to taking an assignment independently. Review of the facility documentation dated [DATE] revealed audits were completed for all Nurse Aides (NA), Nurses, and Paramedics. The facility's Immediate Jeopardy removal date of [DATE] was confirmed.