**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and intervene for a change in condition for:1. Resident #8 who reported chest pain on [DATE] at 7:46 a.m. A progress note showed vital signs were taken, but no other action was documented, and2. Resident #7 who was reported by RN #1 to be slumped over the table in the dining room on [DATE] during the noon meal. The note showed Resident #7 was removed from the dining room and taken to their room. No other actions were documented.On [DATE] at 12:06 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On [DATE] at 12:45 p.m., the DON and administrator were notified of the IJ situation and provided the IJ template.On [DATE] at 11:41 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Plan of Removal: IJ for Failure to Assess, Monitor [and] InterveneCorrective Actions TakenImmediate Clinical Response:Nurse managers and charge nurses completing facility wide assessments of all residents to establish baselines. If concerns are found, notify DON, the party responsible and residents Physician immediately to get orders in place. The Medical Director was notified immediately and made aware of IJ status and action plan of interventions.All policies on change of condition, monitoring, and interventions reviewed and revised. Clinical systems revised to flag key indicators requiring escalation via E-interact and Change of Condition communication forms. E- Interact will populate to the Clinical Dashboard and 24-hour report. Staff Notification:All clinical staff were informed of the deficiency and advised of immediate changes in protocol. That includes the implementation of the E-Interact and the Change in Resident Status communication form.A mandatory in-service training was immediately scheduled and will be completed within 24 hours.Any staff that are not able to complete training within 24 hours will be required to complete training prior to working next scheduled shift. Education & TrainingEmergency Staff Education:Licensed nurses and CNAs received training on policy and procedure over Change in Resident Status or Conditions.Focus included documentation, escalation pathways, and timely physician notification.Educated and implemented use of E- Interact SBAR (Situation-Background-Assessment-Recommendation) and utilization of Change in Resident Status communication form. Competency Validation:Senior Director of Clinical Services trained Director of Nursing over processes of implementation of E- Interact SBAR (Situation-Background-Assessment-Recommendation) and utilization of Change in Resident Status communication form.Director of Nursing trained nurse management and charges nurses over processes and implementation of E- Interact SBAR (Situation-Background-Assessment-Recommendation) and utilization of Change in Resident Status communication form.Staff will verbalize understanding of training and observation of change in condition and assessment. RN Supervisor Role Expansion:DON will perform daily audits of residents with identified clinical risks.Shift Huddles Introduced:Begin and end-of-shift meetings instituted to identify potential high-risk residents starting [DATE]. Date of Compliance:Compliance Date: [DATE]The IJ was lifted, effective [DATE] at 12:25 p.m., when all components of the plan of removal had been verified as completed. Review of policy changes for change of conditions was conducted, clinical system changes were reviewed, review of the resident assessments for all 55 residents were completed, clinical staff were interviewed regarding changes in policy for change of condition, communication with facility staff and timely notification to physician of a change in condition. The DON was interviewed regarding in-service with the senior director of clinical services and daily audits of residents at risk. Review was completed of the Beginning and end of shift meetings documentation sheets. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to assess, monitor, and intervene for a change in condition for 2 (#7 and #8) of 3 sampled residents reviewed for a change in condition.The administrator identified 55 residents resided in the facility. Findings:1.A physician's order for Resident #8, dated [DATE], showed to administer a 24-hour nitroglycerin patch 0.1mg/hour transdermally in the morning related to angina pectoris and to take off after 24 hours.An annual assessment, dated [DATE], showed a BIMS of 15 which indicated Resident #8 was cognitive for daily decision making. The assessment showed diagnoses which included diabetes, heart failure, hypertension, angina pectoris, and end stage renal disease.The [DATE] MAR for Resident #8 showed the nitroglycerin patch was not administered on [DATE]. The MAR showed routine simethicone 80 mg for gas and as needed calcium carbonate (Tums an antacid) were not administered for indigestion on [DATE]. A progress note, dated [DATE] at 7:46 a.m., showed Resident #8 complained of chest pain and vital signs were within normal limits. The note showed Resident #8 stated the chest pain was probably indigestion. No other assessment was documented. The note did not show the physician was notified. The note was entered by RN #1,A progress note, dated [DATE] at 11:30 a.m., showed Resident #8 was found without breath and pulse, CPR was started, notification was made to the DON, ADON, and emergency medical services authority. The note did not show the physician was notified. The note was entered by RN #1.A progress note, dated [DATE] at 1:24 p.m., showed the physician was notified of Resident #8 passing at the facility and an order was received to release the body to the funeral home.On [DATE] at 10:48 a.m., RN #1 stated on the morning of [DATE] Resident #8 reported pressure in their chest, their vital signs were within normal limits, and they asked Resident #8 if they thought it was chest pain or indigestion. RN #1 stated Resident #8 replied they thought it was indigestion and Resident #8 went back to bed. They stated later they looked back in on Resident #8 in their room, and they were lying on the bed with their back to the door. RN #1 stated they assumed Resident #8 was sleeping, then left the room, and checked blood sugars for other residents. RN #1 stated when they returned to Resident #8 at 11:30 a.m., they found Resident #8 without breath and pulse. They stated Resident #8 had been complaining about not feeling well for a couple of weeks.2.An admission assessment for Resident #7, dated [DATE], showed diagnoses which included cerebral vascular accident (CVA/stroke), transient ischemic attack (TIA/mini stroke), and Parkinson's disease.A care plan for Resident #7, revised [DATE], showed no concerns for CVA or TIA.The [DATE] MAR showed on Friday [DATE] a blood pressure of 162/103 was recorded. There was no follow up blood pressure recorded and no assessment was located in the clinical record. Review of progress notes showed no progress note for [DATE].A progress note, dated [DATE], showed Resident #7 was unable to sit up and eat at lunchtime. The note showed Resident #7 kept falling forward and putting their head on the table and then Resident #7 was returned to their bed by RN #1. No actions were recorded in the progress. The note was documented by RN #1.A progress note, dated [DATE], showed the representative for Resident #7 came to the nurse's station and stated they thought Resident #7 had a stroke and it had to have happened earlier in the day. The note showed the representative wanted Resident #7 sent to the emergency room for evaluation. The note showed 911 was called and Resident #7 was taken to the emergency room. The note was documented by LPN #1.Hospital records for Resident #7, dated [DATE] at 11:10 p.m., showed results of a CT chest procedure. The results showed findings of a pulmonary emboli in the distal right pulmonary artery.On [DATE], at 8:50 a.m., the representative for Resident #7 stated they had found Resident #7 on [DATE] at 7:00 p.m., in the dining room, slumped over with a peanut butter sandwich in their hand. They stated they told the nurse to call 911 because Resident #7's face was drooped. The representative for Resident #7 stated the hospital informed them Resident #7 had a pulmonary embolism.On [DATE] at 9:40 a.m., CNA #4 stated they tried to feed Resident #7 their breakfast on [DATE], but they were sleepy. They stated they tried to talk to Resident #7, but the resident did not talk to them and would not eat the pancake. CNA #4 stated Resident #7 was sitting up straight in their wheelchair. On [DATE] at 9:52 a.m., CMA #1 stated Resident #7 seemed sleepy on [DATE], but took their medications fine. They stated Resident #7 was slumping over the table and it was unusual. CMA #1 stated they did not report the unusual behavior to anyone.On [DATE] at 10:15 a.m., CNA #3 stated Resident #7 was very quiet and did not eat as well as usual on [DATE]. They stated Resident #7 seemed out of it and was not as alert as they usually were. CNA #3 stated Resident #7 had some drooping on the right side of their face. They stated during dinner Resident #7 was bent over the table, but did not report that to anyone. CNA #3 stated they thought it was because Resident #7 was tired. On [DATE] at 10:30 a.m., CNA #1 stated they saw Resident #7 on [DATE] in the dining room staring off into space. They stated Resident #7 was leaning to the right and they straightened Resident #7 up in their wheelchair. CNA #1 stated they did not report it to anyone because they did not think it was unusual.On [DATE] at 10:35 a.m., CNA #2 stated on [DATE] Resident #7 seemed a little tired at lunch and for a moment Resident #7 kind of got a strange look on their face. CNA #2 stated when Resident #7 was questioned about how they felt they stated they were okay. They stated the ADON was at the table and thought Resident #7 was okay as well.On [DATE] at 10:39 a.m., LPN #1 stated on [DATE] they were getting ready to leave for the day and the representative for Resident #7 approached them at approximately 7:00 p.m., and stated Resident #7 had a stroke and needed to be sent out to the emergency room. They stated the representative informed them Resident #7 was slumped over when they came in and did not look right. LPN #1 stated they had not noticed anything unusual with Resident #7 during dinner because they were feeding two other residents. On [DATE] at 10:54 a.m., RN #1 was asked about their progress note entered on [DATE]. They stated on [DATE] Resident #7 was sleeping at the table in the dining room for lunch and it was not unusual. RN #1 stated very seldom would Resident #7 have their eyes open while they were fed and did not really respond in any way. They stated Resident #7 was frequently drowsy, as they were that morning and would not open their mouth. RN #1 stated they felt if Resident #7 was leaning and unable to sit up they would be better off in bed, so they took Resident #7 back to their room. They stated they did not remember if they had completed an assessment on Resident #7, but if they had, the assessment would be in the progress note. RN #1 stated the did not think they would have charted an assessment because it was not unusual. They stated if Resident #7 was leaning they wanted them safe, and it just seemed out of the ordinary Resident #7 was leaning, but everything else seemed within normal limits. RN #1 was asked if they were made aware of a blood pressure on Friday [DATE]. They stated they remembered the CMA had reported a blood pressure for someone being elevated, but could not recall who the resident was. RN #1 stated the blood pressure should have been rechecked. RN #1 was asked what the follow up was for the elevated blood pressure. They stated, Something was missed.On [DATE] at 12:15 p.m., the DON with the administrator present was asked what the policy/protocol was for documentation. They stated nurses documented by exception. The DON was informed of the progress note on [DATE] for Resident #7 and that the note did not show an assessment was completed or the physician was notified. They stated an assessment should have been conducted and the physician should have been notified. The DON was asked why an assessment was not completed if this was documented as an exception. They stated they would have to check. The DON was asked what the policy/protocol was regarding an elevated blood pressure. They stated the blood pressure should have been reported verbally to the nurse who should have rechecked the vital signs. The DON was asked how they would know if the blood pressure was not reported to the nurse. They stated they would not know. The DON was asked why the physician was not notified of the elevated blood pressure on Friday [DATE] for Resident #7. No answer was provided. The DON was asked what the policy/protocol was regarding reports of chest pain. They stated it depended on who it was reported to. The DON stated the nurses checked vital signs and did an assessment/physical exam to determine appearance of symptoms such as if the resident looked short of breath or not and ask what kind of pain or characteristics of the pain. They stated if pressure were reported the nurse would notify the doctor. The DON was asked why RN #1 did not follow protocol. They stated they did not know.