**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, review of information from the Cleveland Clinic regarding hypotension, and interviews, the facility failed to ensure staff identified a change in condition for Resident #22 when the resident experienced hypotension (low blood pressure) and diaphoresis (sweating especially to an unusual degree as a symptom of disease) and failed to notify the physician of the resident's hypotension and diaphoresis resulting in a delay in care and treatment. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm beginning on 08/03/24 at 3:15 P.M. when Resident #22, who had a history of hypertension (high blood pressure), had a blood pressure of 93/51 millimeters of mercury (mm/Hg) which was not reported to the physician and no treatment was provided. Resident #22's family member requested the resident be sent to the hospital for evaluation on 08/03/24 at 7:33 P.M. (four hours after the resident first exhibited a decline in condition) due to the resident's continued hypotension and diaphoresis. Resident #22 was admitted to the hospital on [DATE] with diagnoses of septic shock and encephalopathy and expired at the hospital on [DATE]. This affected one (#22) of four residents reviewed for falls. The facility census was 88. On 09/11/24 at 11:42 A.M., President #218, Director of Nursing (DON), and Assistant Director of Nursing (ADON) #226 were notified Immediate Jeopardy began on 08/03/24 at 3:15 P.M. for Resident #22, when staff failed to inform the resident's physician of a change in condition when Resident #22 began to complain of pain, was diaphoretic, and hypotensive thereby delaying care and treatment, until Resident #22's family arrived to the facility and requested the resident be sent to the emergency department for further evaluation. Consequently, Resident #22 was admitted to the hospital with diagnoses of septic shock, hypotension, and hypothermia. The resident expired at the hospital on [DATE]. The Immediate Jeopardy was removed on 09/12/24 when the facility implemented the following corrective actions: • On 09/11/24 at 1:15 P.M., the facility will continue with its staff education and monitoring program specifically to ensure that any and all pertinent policies and procedures regarding resident changes in condition to ensure staff are implementing them as directed to prevent the same actions, situations, and/or practices from occurring in the future, by conducting in-service education via the employee communication system which will include all clinical employees. This was completed on 09/11/24 at 1:15 P.M. and included eight Registered Nurses (RN), 22 Licensed Practical Nurses (LPN) and 35 State Tested Nursing Assistants (STNA). Education will be ongoing. • On 09/11/24 at 2:00 P.M., ADON #226 sent out the education notification immediately to alert nursing staff to notify the physician immediately when a change of resident condition occurs. • On 09/11/24 at 2:00 P.M., the DON completed counseling and education with LPN #185 regarding proper documentation and communication with physician regarding resident change in condition. • On 09/11/24 at 2:00 P.M., the facility will continue to ensure there are systems in place to complete ongoing assessments of residents' health status when they experience a change in condition as evidenced by the following: When a resident has a change in condition, if indicated, the nurse may complete a Change of Condition Assessment in Point Click Care; the form is located under the Assessments tab in the resident electronic medical record. The change of condition includes along with any labs, analysis, x-rays, notification with physician date and time along with notification of responsible party date and time. After the completion of the assessment, if indicated, the attending physician will be notified immediately. Change of condition assessment form has been activated and implemented. The facility will continue to ensure that staff notify the attending physician immediately for any potential changes in treatment when a change in condition occurs. This is implemented and effective. • Beginning on 09/11/24 at 2:00 P.M., all 90 residents in the facility will have a head-to-toe assessment and will be assessed for abnormal vital signs, abnormal change in mental status, any skin issues, and complaints of pain by 7:00 P.M. on 09/11/24. This will be done by the attending charge nurses. Results will be noted in resident's chart and a progress note will be completed. If there are any signs of change in condition the physician will be notified immediately, and the change of condition assessment will be completed. The facility will continue to both assess and reassess all current residents for potential changes in condition, notification of physician, and any needed revisions to the plan of care to ensure potential issues are appropriately addressed and followed through on. This action was verified by the surveyor with record reviews for Residents #28 and #29. • On 09/11/24 at 2:00 P.M., education will be provided to each nurse 1:1 and the employee will be shown the policy and procedure for the change in condition and the physician of notification. The employee will be shown where to find the change of condition assessment and the information it requires. The employee will demonstrate back showing how to find the assessment and where the policy is located. This education will be completed by the start of each nurse's next shift. This will be completed by ADON #226 for dayshift staff and RN #194 for nightshift staff. • On 09/11/24 at 3:00 P.M., the charting guideline policy was reviewed by the DON and ADON #226 to include changes reflective of electronic charting. Information removed consisted of paper documentation and frequency of monitoring systems. The changes now adhere to our current frequency and monitoring systems and inclusive of the change in condition assessment. • On 09/12/24, interview with LPN #210 at 8:52 A.M., STNA #248 at 8:58 A.M., LPN #214 at 9:00 A.M., LPN #253 at 10:31 A.M., and LPN #282 at 10:36 A.M. revealed the staff had received education and in-service training on change in condition, physician notification, and documentation and were knowledgeable about the facility's procedures and processes. • On 09/12/24 at 9:30 A.M., the facility began implementation of the change in condition assessment information to be reviewed during daily morning clinical meeting. It will begin on this date and time and will be ongoing indefinitely. • On 09/13/24 at 9:30 A.M., the quarterly Quality Assurance and Performance Improvement (QAPI) meeting is scheduled and will take place to include all day shift supervisors, MDS, Director of Therapy, Director of Nursing, Assistant Director of Nursing, Director of Food Services, Director of Environmental Services, Social Services, Activity Director, Medical Director, and the Administrator. During this meeting, we will address the revised policy on change in condition and physician notification. • Beginning on 09/16/24, the DON or designee will perform auditing of any change of condition in the facility. The audit will consist of three random residents, twice a week for four weeks and will be monitored monthly for three months. We will be auditing that a change of condition assessment was completed based off our review in clinical meeting from the 24-hour report. All changes to a resident condition will be communicated with families or power of attorney's when it occurs. Although the Immediate Jeopardy was removed on 09/12/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine if further action is required and monitoring to ensure on-going compliance. Findings include: Closed record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic obstructive pulmonary disease, weakness, dementia, and hypertension. Review of the order summary revealed Resident #22 had an order in place for assist of two for bed mobility and Hoyer lift for transfers (12/06/23) and an order for Tylenol oral tablet 325 milligrams (mg) give two tablets by mouth every six hours as needed for pain (06/01/23). Review of a care plan dated 07/03/24 revealed Resident #22 had an activity of daily living (ADL) self-care performance deficit related to impaired balance and obesity. Interventions included two staff assistance with any care given while resident is in bed (06/23/23), resident is totally dependent on two staff to turn and reposition in bed as necessary (07/15/20), resident is totally dependent on two staff to provide shower (07/15/20), to provide a sponge bath if a shower cannot be tolerated (07/03/20), and resident is totally dependent on two staff for transferring with a mechanical lift (07/15/20). Review of a quarterly Minimum Data Set (MDS) assessment collected on 07/26/24 revealed Resident #22 had mildly impaired cognitive function, no behaviors, required dependence of staff for care for bathing, toileting, dressing, bed mobility, and transfers. Review of a Morse Fall Scale assessment completed on 08/02/24 revealed Resident #22 was a moderate risk for falling. Review of the medical record revealed the following vital signs for Resident #22: On 08/01/24 at 11:19 A.M., blood pressure (BP) was 160/88 mm/Hg; at 5:16 P.M., BP was 168/77 mm/Hg. On 08/02/24 at 10:14 A.M., BP was 154/83mm/Hg; at 5:28 P.M., BP was 165/65 mm/Hg. On 08/03/24 at 9:34 A.M., BP was 148/65; at 11:45 A.M., BP was 137/62 mm/Hg (prior to the resident's fall). The resident's body temperature was recorded on 08/03/24 at 6:15 P.M. as 97.6 degrees Fahrenheit (F) (location, forehead). Review of a nursing note dated 08/03/24 at 11:52 A.M. by Licensed Practical Nurse (LPN) #185 revealed a State Tested Nursing Aide (STNA) informed the nurse Resident #22 was rolled out of bed while receiving a bed bath but did not hit her head during the fall. Upon entering the room, Resident #22 was found lying on her back on the floor next to the bed, she was alert and immediately assessed for pain. Resident #22 denied pain but did have abrasions to left index and middle fingers, vital signs were within normal limits, and resident was assisted back into bed with the assistance of four staff and neuro checks were initiated. The nurse called Resident #22's son and made him aware of the situation. Review of a Neurological Check assessment completed on 08/03/24 at 12:00 P.M. revealed Resident #22's blood pressure was 123/58 mm/Hg (normal blood pressure is 120/80 mm/Hg). Review of a Counseling Form completed on 08/03/24 at 12:15 P.M. by the DON with STNA #130 revealed the seriousness of the situation was explained, STNA #130 stated she attempted completing Resident #22's care by herself because she thought she could do it, and the DON instructed her to clock out and informed her she was terminated. Review of a Neurological Check assessment completed on 08/03/24 at 12:15 P.M. revealed Resident #22's blood pressure was 110/57 mm/Hg; an assessment completed at 3:15 P.M. revealed Resident #22's blood pressure was 93/51 mm/Hg, she was complaining of pain rated at four out of 10 and she was grimacing, withdrawing, or showing other non-verbal signs of pain. Review of a nursing note dated 08/03/24 at 3:40 P.M. by LPN #185 revealed Resident #22 was having complaints of increased pain to her left knee, the on-call provider was contacted and gave a new order for STAT (immediate) three-view x-ray of left knee. No new orders were received for pain management. There was no evidence the on-call provider was notified of the resident's low blood pressure (110/57 mm/Hg and 93/51 mm/Hg). Review of a medication administration record (MAR) for August 2024 revealed Resident #22 did not receive as needed Tylenol per orders when complaining of pain on 08/03/24. Review of a Neurological assessment dated [DATE] at 4:15 P.M. revealed Resident #22's blood pressure was 98/50 mm/Hg; at 5:20 P.M. her blood pressure was 93/60 mm/Hg and at 6:21 P.M. her blood pressure was 95/60 mm/Hg. There was no evidence the resident's medical provider was notified. Review of a nursing note dated 08/03/24 at 7:01 P.M. by LPN #185 revealed Resident #22 had an x-ray completed to her left knee and was awaiting results. Resident #22 was very diaphoretic and stated she was cold. Vital signs were checked, blood glucose was checked, and no abnormalities noted. There was no evidence the resident's medical provider was notified of the resident's condition including the previous low blood pressure readings and diaphoresis. Review of a nursing note dated 08/03/24 at 7:33 P.M. by LPN #185 revealed Resident #22 was sent out to the hospital at the request of her family for further evaluation related to increased diaphoresis and pain all over. On-call provider was notified and gave the order to send to the emergency room for evaluation. Review of a hospital History and Physical dated 08/04/24 revealed Resident #22 came to the hospital and presented with septic shock with hypothermia and encephalopathy, a history of extended-spectrum beta-lactamase (ESBL) (an enzyme produced by some bacteria that can make them resistant to certain antibiotics. ESBL producing bacteria are harder to treat and may require complex treatments) and had (urine) cultures pending, acute kidney injury, and elevated troponin levels with a history of coronary artery disease. Resident #22 suffered from a fall while at a nursing facility, afterwards they got her up and she was sweating and did not appear to feel well. During assessment, Resident #22 was confused and unable to answer questions regarding the day, month, year, or date. Review of a critical pulmonology note dated 08/04/24 revealed Resident #22 admitted to the emergency room after diaphoresis and low blood pressure. Resident #22 had been in her room with multiple blankets on and no air conditioning (at the nursing home). At the hospital her blood pressure continued to drop to 49/34 mm/Hg and her temperature was 95.4 degrees Fahrenheit. Review of a hospital note dated 08/04/24 revealed overnight, Resident #22 suffered from respiratory failure (related to aspiration while at the hospital) and worsened hypotension. She was placed on a ventilator. Review of a nursing note dated 08/04/24 at 11:51 P.M. by LPN #275 revealed Resident #22's son called and notified the facility Resident #22 expired. Interview on 08/30/24 at 12:51 P.M. with Resident #22's family revealed the evening of 08/03/24, they came to visit the resident, and she was very sweaty and disoriented. They stated this was abnormal for her and they had to request staff to send her to the hospital. Interview on 08/31/24 at 1:25 P.M. with the DON confirmed Resident #22 had an order and care plan interventions in place for assist of two which was not followed. Interview on 09/04/24 at 2:31 P.M. with LPN #185 revealed on 08/03/24 after she had finished medication pass, the STNA came up the hall and informed her she was giving Resident #22 a bed bath and had rolled her out of the bed. The STNA stated she did not have a second person, and LPN #185 immediately educated the aide. LPN #185 stated she went to Resident #22 to assess her, her vitals were normal, she hadn't hit her head, but the cranial checks were started. LPN #185 stated she had notified the physician and the DON. LPN #185 stated Resident #22 was stable and had no complaints of pain once in bed. As the day progressed, Resident #22 complained of pain and was sweating really bad, so an order was received for an x-ray. After the x-ray was completed, Resident #22's son came in and was concerned so he requested Resident #22 be sent to the hospital for additional evaluation. LPN #185 stated Resident #22 started sweating in the afternoon, after lunch but before dinner. LPN #185 stated that is also when Resident #22 started to have low blood pressure. LPN #185 stated sometimes Resident #22 would have high blood pressure and sometimes it would be low. LPN #185 stated she could not recall how soon after Resident #22 became diaphoretic she contacted the provider, but no new orders were received for pain medication and the as needed Tylenol was not administered. LPN #185 stated low blood pressure was not concerning to her. When asked what diaphoresis and hypotension could be indicators for, LPN #185 stated it could be a sign of sepsis or a bleed. LPN #185 confirmed since Resident #22 had medical health problems and had been rolled out of bed earlier in the day, the hypotension and diaphoresis should have been more concerning. LPN #185 confirmed she did not request to send Resident #22 to the hospital prior to 7:33 P.M. (on 08/03/24). LPN #185 stated she had been about to call the provider to update them on Resident #22's status when the family requested the resident to be sent to the hospital. Interview on 09/04/24 at 4:19 P.M. with the DON revealed the low blood pressure was not concerning because people can have numbers that low and be normal and would not be a reason to send someone to the hospital. The DON stated she could not comment on the combination of hypotension along with diaphoresis because she did not see it in person. The DON stated Resident #22 was always cold and there was nothing abnormal about her symptoms. The DON did confirm nursing notes did not display the resident's medical provider or physician were made aware of the diaphoresis or hypotension until Resident #22's son requested for her to be sent to the hospital. Interview on 09/10/24 at 9:45 A.M. with Physician's Assistant (PA) #400 (Resident #22's primary care provider) revealed he was made aware either on 08/05/24 or 08/07/24 because Resident #22 was a long-term patient and the last time he had seen her was the end of June (2024). PA #400 stated he remembers going to the facility on Wednesday (08/07/24) and he didn't see Resident #22 on point click care (PCC) and when he asked where she was, the facility staff explained to him that she passed away. PA #400 confirmed he was not made aware at the time of the fall on 08/03/24 due to not being on-call over the weekend of the incident. PA #400 stated a normal blood pressure for Resident #22 ranged from about 110-168 (systolic)/57-88 (diastolic). PA #400 confirmed Resident #22's vitals appeared to be stable on 08/03/24 until about 3:15 P.M. PA #400 revealed due to not being on-call, he was not made aware of the change in condition, but a provider should have been made aware of a change in Resident #22's blood pressure if other symptoms of something were present. Interview on 09/10/24 at 10:56 A.M. with Nurse Practitioner (NP) #410 (works for the on-call medical provider company that cover the facility on weekends) revealed she was not aware Resident #22 had been rolled out of bed during care provided by one staff member on 08/03/24. NP #410 stated after three in the afternoon (on 08/03/24), she was called because Resident #22 had fallen out of bed and was complaining of knee pain. NP #410 stated she did order an x-ray. NP #410 confirmed she was not made aware of Resident #22 being diaphoretic or hypotensive. NP #410 stated she could not recall when she was made aware Resident #22 went to the hospital and she did not have access to the system to look. NP #410 stated if she had known during the afternoon phone call, she received regarding Resident #22's pain, that Resident #22 also was diaphoretic and hypotensive, since she was unaware of Resident #22's medical history, she would have sent the resident to the hospital for evaluation. Review of the Cleveland Clinic website (undated) revealed symptoms of low blood pressure include confusion or trouble concentrating and unusual changes in behavior. A low blood pressure is considered to be less than 90 for systolic and less than 60 for diastolic. This deficiency represents non-compliance investigated under Complaint Number OH00156609.