**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #63) of 4 residents reviewed for physician notification. The facility failed to notify the physician of change of condition which led to Resident #63 going into respiratory and cardiac arrest and was pronounced dead after transfer to the hospital on [DATE]. An Immediate Jeopardy was identified on [DATE] at 2:40 pm. The IJ template was provided to the facility on [DATE] at 2:40 pm. While the IJ was removed on [DATE] at 3:18 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for not receiving emergency care and further life-saving treatments as desired, that could lead to serious illness, hospitalization, and/or death. Findings Include: Review of Resident #63's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: fractured femur, breast cancer, and muscle weakness. Further review of the electronic face sheet revealed discharged [DATE] to acute care hospital. Review of Resident #63's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 15 which indicated no impaired cognition. Section I Active Diagnosis revealed Resident #63 had cancer and high blood pressure. Further review revealed no cardio or respiratory diagnosis. Review of Resident #63's care plan, initiated [DATE], revealed: Focus: Resident has a code status of Full Code/CPR. Goal: Resident wishes to be a Full Code/CPR will be honored. Interventions: If resident arrest CPR will be performed, 911/EMS called, MD/RP informed. Further review of care plan revealed no evidence of respiratory or cardiac issues and no evidence of the use of oxygen. Review of Resident #63's electronic physicians orders from [DATE] to [DATE], revealed no evidence of any oxygen orders. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 9:00 pm, signed by LVN A, revealed: resident c/o feeling weak, pain to extremities, VS 97.8, 64, 20, 104/56, SPO2 81%@ RA, applied O2 @ 2lpm/NC, SPO2 up to 94%, respirations unlabored, administered PRN APAP#3 (Tylenol #3), resident drank approximately 240cc of H20, resident then vomited, VS remain 97.7,71, 20, 107/60, SpO2 93%@2lpm/NC. Review of Resident #63's electronic record from [DATE]-[DATE], revealed no evidence of any respiratory or lung assessments completed. Further review of Resident #63's record revealed no evidence of physician notification or change or condition. Review of Resident #63's electronic nurse's progress notes from [DATE] to [DATE] revealed no evidence of follow up assessments or monitoring after oxygen was administered. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 05:00 am, signed by LVN A, revealed: resident has had no further Nausea/vomiting this shift, continues to c/o pain to BLE, VS remain stable, SpO2 93-95%@2lpm/NC, has drank approximately 240-480cc of fluids this shift, alert, oriented, able to make needs known. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 07:30 am, signed by RN B, revealed: CNA came to nurse stating resident not responding-this nurse entered room resident not breathing-not responding to verbal or tactile stimulation-RN call for help CPR initiated and LVN called 911- 7:35 ems arrived, and CPR continued - MD/[family member] notified-8am ems departed with resident cpr still in progress. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 10:43 am, signed by RN B revealed: Hospital notified states resident expired. Review of Resident #63's hospital clinical record dated [DATE], revealed: 8:21 am CPR was continued on arrival to emergency room without any change. 8:32 am expired due to cardiac and respiratory arrest During an interview on [DATE] at 3:30 pm, the DON stated the physician, and the family should have been notified on [DATE] at 9:00 pm when Resident #63 had a change of condition requiring oxygen placement. She stated a change of condition assessment should have been completed. The DON stated Residents #63 should have been monitored closely throughout the night. She stated she did not feel that it was a significant enough change for her to have been notified. The DON stated she felt that the nurse had probably notified the doctor and just forgot to document it. She stated it was probably just a hectic night and the nurse forgot to document her assessments and any further monitoring throughout the night. The DON stated CNA F no longer worked at the facility. During an interview on [DATE] at 4:00 pm, the Physician stated she was notified on [DATE] that Resident #63 had coded and was sent to the emergency room. She stated she was not notified the night before of the resident change in condition and requiring oxygen. The physician stated she expected to be notified of any change of condition and that any resident who previously did not require oxygen and then does was considered a significant change in condition. She said she would have sent Resident #63 to the emergency room or at least started treatment on the night of 5/01 had she been notified because she had already discussed this with Resident #63 and the resident wanted aggressive treatment. The Physician stated it was a delay in care and she could have been treated 10 hours earlier possibly preventing the code and the death. During an interview on [DATE] at 4:45 PM, LVN A stated Resident #63 had a low blood pressure and low oxygen saturation on 05/01 at 9:00 pm. She stated she applied oxygen, and that Resident #63 had a prn oxygen order. She stated she texted the physician but did not get a reply, but she was not concerned because she did not feel that anything was wrong with Resident #63. She stated she did not perform a lung assessment because the resident did not seem distressed. She stated she did not consider it a change in condition and did not complete a change in condition assessment. She stated she and her CNA did check on the resident throughout the night, but she just forgot to document it. During an interview on [DATE] at 5:02 PM, RN B stated she was notified of nurse aides that Resident #63 was found unresponsive at the time of shift change. During an interview on [DATE] at 5:04 PM, CNA H stated she walked into Resident #63's room, found resident non-responsive, and notified RN B immediately. She stated this occurred at shift change. During an interview on [DATE] at 1:56 PM, the ADMN stated her expectation was to call the physician with any change of condition. She stated if a residents oxygen level decreased and staff was having to address that, staff should have contacted the physician and the DON, but only if the resident needed orders outside of resident's parameter orders. Attempted interview on [DATE] at 11:09 AM with CNA F who worked on the night of [DATE] and she did not answer. During an interview on [DATE] at 01:00 PM, CNA G stated she worked the night of [DATE] and was aware of Resident #63's episode at 9:00 pm. She stated she notified LVN A that the resident was having difficulty breathing and the nurse applied oxygen to the resident. She stated she was not in charge of care for that resident and was unaware of her status the rest of the night. She stated CNAs did not document every 2 hours. She stated they complete once a shift documentation. CNA stated there was no way to prove that residents were rounded on every 2 hours. Record review of the policy titled, Change in a Resident's Condition or Status, last revised [DATE] read in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .2. A significant change of condition is a major decline or improvement in the resident's statue that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provide, including information prompted by the Interact SBAR Communication Form. Record review of the policy titled, Oxygen Administration, last revised [DATE] read in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis; 2. Signs or symptoms of hypoxia; .4. Vital signs; 5. Lung sounds .Procedure .13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . This was determined to be an Immediate Jeopardy on [DATE] at 2:40 PM. The ADMIN was notified. The ADMIN was provided with the IJ template on [DATE] at 2:40 PM. The following Plan of Removal was submitted by the facility was accepted on [DATE]at 1:06 PM: Impact Statement: On [DATE] an abbreviated survey was initiated. On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide treatment and care to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility DON and nurse management team completed an audit to address potential change of conditions on all residents using the 24/72-hour report on [DATE]. All residents had the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident #1 no longer resides in the building as of [DATE]. What corrective actions were taken? 1. The following actions were initiated immediately on [DATE] a. On [DATE] an audit was completed by the DON and/or designee to identify all residents who were at risk for having a change in condition in last 30days related to their disease process including reviewing all Oxygen orders in last 30days. No residents were identified to be affected. DON and ADON were educated on [DATE] by CSD (Clinical Service Director) on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents. Change in condition will be reported/monitored with the Stop and Watch tool and SBAR. When a change in condition has been identified it will be placed on the shift-to-shift charge nurse report and also reported in the morning clinical meeting by the charge nurse. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. b. On [DATE] an in-service was initiated for all Licensed Nurses, on change of condition, notifying the physician of changes. All staff who are unable to attend will be required to complete training before their next scheduled shift. Inservice was completed on [DATE] and will be monitored and review for effectiveness by DON During QAPI. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. c. On [DATE] an in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. All nursing staff unable to attend will be required to complete training before their next scheduled shift. Inservice was completed on [DATE] and will be monitored and review for effectiveness by DON During QAPI. 2. How will the system be monitored to ensure compliance? d. The ADON, DON and/or designee will review the facilities 24/72-hour summary report in PCC 5 days per week in the morning clinical meeting starting on [DATE] for 4 weeks and then ongoing to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention. Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented. Any identified concerns will be addressed immediately, and additional training will be provided as needed. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. e. The DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified. Starting on [DATE] and will be ongoing. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. f. The weekend supervisor and/or designee was in-serviced on [DATE] by DON on how to review the 24/72-hour report from PCC and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified. Nursing staff will contact the physician and ensure appropriate orders and interventions are in place. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. g. Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician during orientation by the DON or designee. Staff unable to come to receive training will be required to completed training before their next scheduled shift. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of the facility's Plan of Removal through interviews and record reviews from [DATE] at 1:06 pm through [DATE] at 3:00 pm revealed: During an interview on [DATE] at 01:51 PM, the DON stated she ran 24-hour report and ran an order listing report that would encompass all new orders. She stated looked at all residents' vital signs including weight and nurses' documentation to identify residents who were at risk. She stated that any change of condition including administering O2, staff would have to contact MD with changes and then anything that was not normal had to be documented as MD notified. The DON stated if there was not an answer from doctor then they would continue to try to contact and if they could not get ahold of the physician then nurses will contact DON or ADMN to notify the Medical Director. She stated the Medical Directors had been notified of POR and the Medical Directors have been notified that if staff were unable to reach attending, then she would be notified. The DON stated changes in condition would be discussed in morning meeting and be documented on a 24-hour report with VS, falls, and new orders in the clinical meeting and everything from previous day would be reviewed. The DON stated she would monitor that the in-services were effective by looking at the dashboard on PCC to see if alerts have been cleared out. She stated she would monitor that physicians were being notified by monitoring nurses notes to verify that change in condition was followed up on. The DON stated she had remote access to PCC. She stated the weekend supervisor would be the DON and ADON every weekend and that one of them would look at the reports and monitor/review 24/72-hour report from PCC. During random interviews via phone on [DATE] at 1:15 PM, revealed 2 Licensed Nurse and 1 Registered Nurse who worked the 12-hour night shift had been educated regarding change of condition and notifying the physician of changes. During random interviews on [DATE] at 2:15 PM, revealed 1 Licensed Nurse and 1 Registered Nurse who worked the 12-hour day shift had been educated regarding change of condition and notifying the physician of changes. Review of written in-service initiated on [DATE] about Change of Condition - Administering O2 - Contacting MD & RP's with changes - Stop n watch - Monitoring after the change of condition - documentation ensure change is on 24 hour report - care planning - monitor nurse alerts require monitoring & documentation. Notify the MD - call - if no answer the nurse will notify DON and/or Administrator and the Medical Director will be notified - Must be documented in the Medical Record. Verified all nurses' signatures on in-service. During random interviews via phone on [DATE] at 1:15 PM, revealed 3 CNAs, who worked the 12-hour night shift had been educated regarding the importance of completing stop and watch forms when there are changes of condition noticed in residents. During random interviews on [DATE] at 2:15 PM revealed 2 CNAs, who worked the 12-hour night shift had been educated regarding the importance of completing stop and watch forms when there are changes of condition noticed in residents. Review of written in-service initiated on [DATE] with CNAs titled Change of condition- Stop N Watch, with 27 signatures. Review on [DATE] at 01:51 PM, revealed QAPI Signature page with: ADMN and MD signatures on [DATE] and DON, ADON, Payroll, BOM, Housekeeping, Maintenance Director, Medical Records, Nutrition Services, Rehab Services Director, Social Service, and Activity Director signatures on [DATE]. The ADMIN was informed that the Immediate Jeopardy was removed on [DATE] at 3:18 PM. The facility remained out of compliance at a scope of isolated with no actual harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure a resident received the necessary treatment and services, consistent with professional standards of practice for 1 of 4 residents (Resident #63) reviewed for hospitalizations. LVN A failed to recognize Resident #63 was having a change in condition when her oxygen saturation was low, she required supplemental oxygen, she vomited, and complained of pain, and no additional assessments of her condition were provided including follow-up assessments of her vital signs. The facility failed to provide basic quality of care to prevent Resident #63 from going into respiratory and cardiac arrest. The resident was pronounced dead after transfer to the hospital on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:40 PM. While the IJ was removed on [DATE] at 3:18 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for not receiving emergency care and further life-saving treatments as desired, that could lead to serious illness, hospitalization, and/or death. Findings Include: Review of Resident #63's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: fractured femur, breast cancer, and muscle weakness. Further review of electronic face sheet revealed discharged [DATE] to acute care hospital. Review of Resident #63's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 15 which indicated no impaired cognition. Section I Active Diagnosis revealed Resident #63 had cancer and high blood pressure. Further review revealed no cardio or respiratory diagnosis. Review of Resident #63's care plan, initiated [DATE], revealed: Focus: Resident has a code status of Full Code/CPR. Goal: Resident wishes to be a Full Code/CPR will be honored. Interventions: If resident arrest CPR will be performed, 911/EMS called, MD/RP informed. Further review of care plan revealed no evidence of respiratory or cardiac issues and no evidence of the use of oxygen. Review of Resident #63's electronic physicians orders from [DATE] to [DATE], revealed no evidence of any oxygen orders. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 9:00 pm, signed by LVN A, revealed: resident c/o feeling weak, pain to extremities, VS 97.8, 64, 20, 104/56, SPO2 81%@ RA, applied O2 @ 2lpm/NC, SPO2 up to 94%, respirations unlabored, administered PRN APAP#3 (Tylenol #3), resident drank approximately 240cc of H20, resident then vomited, VS remain 97.7,71, 20, 107/60, SpO2 93%@2lpm/NC. Review of Resident #63's electronic record from [DATE]-[DATE], revealed no evidence of any respiratory or lung assessments completed. Further review of Resident #63's record revealed no evidence of physician notification or change or condition. Review of Resident #63's electronic nurse's progress notes from [DATE] to [DATE] revealed no evidence of follow up assessments or monitoring after oxygen was administered. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 05:00 am, signed by LVN A, revealed: resident has had no further Nausea/vomiting this shift, continues to c/o pain to BLE, VS remain stable, SpO2 93-95%@2lpm/NC, has drank approximately 240-480cc of fluids this shift, alert, oriented, able to make needs known. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 07:30 am, signed by RN B, revealed: CNA came to nurse stating resident not responding-this nurse entered room resident not breathing-not responding to verbal or tactile stimulation-RN call for help CPR initiated and LVN called 911- 7:35 ems arrived, and CPR continued - MD/[family member] notified-8am ems departed with resident cpr still in progress. Review of Resident #63's electronic nurse's progress notes dated [DATE] at 10:43, signed by RN B revealed: Hospital notified states resident expired. Review of Resident #63's hospital clinical record dated [DATE], revealed: 8:21 am CPR was continued on arrival to emergency room without any change. 8:32 am expired due to cardiac and respiratory arrest During an interview on [DATE] at 3:30 pm, the DON stated the physician, and the family should have been notified on [DATE] at 21:00 when Resident #63 had a change of condition requiring oxygen placement. She stated a change of condition assessment should have been completed. DON stated Residents #63 should have been monitored closely throughout the night. She stated she did not feel that it was a significant enough change for her to have been notified. DON stated she felt that the nurse had probably notified the doctor and just forgot to document it. She stated it was probably just a hectic night and the nurse forgot to document her assessments and any further monitoring throughout the night. DON stated CNA F no longer worked at the facility. During an interview on [DATE] at 4:00 pm, the Physician stated she was notified on [DATE] that Resident #63 had coded and was sent to the emergency room. She stated she was not notified the night before of the resident change in condition and requiring oxygen. The physician stated she expected to be notified of any change of condition and that any resident who previously did not require oxygen and then does is considered a significant change in condition. She said she would have sent Resident #63 to the emergency room or at least started treatment on the night of 5/01 had she been notified because she had already discussed this with Resident #63 and the resident wanted aggressive treatment. Physician stated it was a delay in care and she could have been treated 10 hours earlier possibly preventing the code and the death. During an interview on [DATE] at 4:45 PM, LVN A stated Resident #63 had a low blood pressure and low oxygen saturation on 05/01 at 9:00 pm. She stated she applied oxygen, and that Resident #63 had a prn oxygen order. She stated she texted the physician but did not get a reply, but she was not concerned because she did not feel that anything was wrong with Resident #63. She stated she did not perform a lung assessment because the resident did not seem distressed. She stated she did not consider it a change in condition and did not complete a change in condition assessment. She stated she and her CNA did check on the resident throughout the night, but she just forgot to document it. During an interview on [DATE] at 5:02 PM, RN B stated she was notified of nurse aides that Resident #63 was found unresponsive at the time of shift change. During an interview on [DATE] at 5:04 PM, CNA H stated she walked into Resident #63's room, found resident non-responsive, and notified RN B immediately. She stated this occurred at shift change. During an interview on [DATE] at 1:56 PM, the ADMN stated her expectation was to call the physician with any change of condition. She stated if a residents oxygen level decreased and staff was having to address that, staff should have contacted the physician and the DON, but only if the resident needed orders outside of resident's parameter orders. Attempted interview on [DATE] at 11:09 AM with CNA F who worked on the night of [DATE] and she did not answer. During an interview on [DATE] at 01:00 PM, CNA G stated she worked the night of [DATE] and was aware of Resident #63's episode at 9:00 pm. She stated she notified the nurse that the resident was having difficulty breathing and the nurse applied oxygen to the resident. She stated she was not in charge of care for that resident and was unaware of her status the rest of the night. She stated CNAs did not document every 2 hours. She stated they complete once a shift documentation. CNA stated there is no way to prove that residents were rounded on every 2 hours. Record review of policy titled, Change in a Resident's Condition or Status, last revised [DATE] read in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .2. A significant change of condition is a major decline or improvement in the resident's statue that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provide, including information prompted by the Interact SBAR Communication Form. Record review of policy titled, Oxygen Administration, last revised [DATE] read in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis; 2. Signs or symptoms of hypoxia; .4. Vital signs; 5. Lung sounds .Procedure .13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . This was determined to be an Immediate Jeopardy on [DATE] at 2:40 PM. The ADMIN was notified. The ADMIN was provided with the IJ template on [DATE] at 2:40 PM. The following Plan of Removal was submitted by the facility was accepted on [DATE] at 1:06 PM: Impact Statement: On [DATE] an abbreviated survey was initiated. On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide treatment and care to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility DON and nurse management team completed an audit to address potential change of conditions on all residents using the 24/72-hour report on [DATE]. All residents had the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident #1 no longer resides in the building as of [DATE]. What corrective actions were taken? 3. The following actions were initiated immediately on [DATE] h. On [DATE] an audit was completed by the DON and/or designee to identify all residents who were at risk for having a change in condition in last 30days related to their disease process including reviewing all Oxygen orders in last 30days. No residents were identified to be affected. DON and ADON were educated on [DATE] by CSD (Clinical Service Director) on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents. Change in condition will be reported/monitored with the Stop and Watch tool and SBAR. When a change in condition has been identified it will be placed on the shift-to-shift charge nurse report and also reported in the morning clinical meeting by the charge nurse. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. i. On [DATE] an in-service was initiated for all Licensed Nurses, on change of condition, notifying the physician of changes. All staff who are unable to attend will be required to complete training before their next scheduled shift. Inservice was completed on [DATE] and will be monitored and review for effectiveness by DON During QAPI. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. j. On [DATE] an in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. All nursing staff unable to attend will be required to complete training before their next scheduled shift. Inservice was completed on [DATE] and will be monitored and review for effectiveness by DON During QAPI. 4. How will the system be monitored to ensure compliance? k. The ADON, DON and/or designee will review the facilities 24/72-hour summary report in PCC 5 days per week in the morning clinical meeting starting on [DATE] for 4 weeks and then ongoing to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention. Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented. Any identified concerns will be addressed immediately, and additional training will be provided as needed. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. l. The DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified. Starting on [DATE] and will be ongoing. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. m. The weekend supervisor and/or designee was in-serviced on [DATE] by DON on how to review the 24/72-hour report from PCC and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified. Nursing staff will contact the physician and ensure appropriate orders and interventions are in place. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. n. Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician during orientation by the DON or designee. Staff unable to come to receive training will be required to completed training before their next scheduled shift. The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of the facility's Plan of Removal through interviews and record reviews from [DATE]at 1:06 pm through [DATE] at 3:00 pm revealed: During an interview on [DATE] at 01:51 PM, DON stated she ran 24-hour report and ran an order listing report that would encompass all new orders. She stated looked at all residents' vital signs including weight and nurses' documentation to identify residents who were at risk. She stated that any change of condition including administering O2, staff would have to contact MD with changes and then anything that was not normal had to be documented as MD notified. DON stated if there was not an answer from doctor then they would continue to try to contact and if they could not get ahold of the physician then nurses will contact DON or ADMN to notify Medical Director. She stated the Medical Directors had been notified of POR and the Medical Directors have been notified that if staff were unable to reach attending, then she would be notified. DON stated changes in condition would be discussed in morning meeting and be documented on a 24-hour report with VS, falls, and new orders in the clinical meeting and everything from previous day would be reviewed. DON stated she would monitor that the in-services were effective by looking at the dashboard on PCC to see if alerts have been cleared out. She stated she would monitor that physicians are being notified by monitoring nurses notes to verify that change in condition was followed up on. DON stated she had remote access to PCC. She stated the weekend supervisor would be the DON and ADON every weekend and that one of them would look at the reports and monitor/review 24/72-hour report from PCC. During random interviews via phone on [DATE] at 1:15 PM, revealed 2 Licensed Nurse and 1 Registered Nurse who worked the 12-hour night shift had been educated regarding change of condition and notifying the physician of changes. During random interviews on [DATE] at 2:15 PM, revealed 1 Licensed Nurse and 1 Registered Nurse who worked the 12-hour day shift had been educated regarding change of condition and notifying the physician of changes. Review of written in-service initiated on [DATE] about Change of Condition - Administering O2 - Contacting MD & RP's with changes - Stop n watch - Monitoring after the change of condition - documentation ensure change is on 24 hour report - care planning - monitor nurse alerts require monitoring & documentation. Notify the MD - call - if no answer the nurse will notify DON and/or Administrator and the Medical Director will be notified - Must be documented in the Medical Record. Verified nurses' signatures on in-service. During random interviews via phone on [DATE] at 1:15 PM, revealed 3 CNAs, the importance of completing stop and watch forms when there are changes of condition noticed in residents. During random interviews on [DATE] at 2:15 PM revealed 2 CNAs, the importance of completing stop and watch forms when there are changes of condition noticed in residents. Review of written in-service initiated on [DATE] with CNAs titled Change of condition- Stop N Watch, with 27 signatures. Review on [DATE] at 01:51 PM, revealed QAPI Signature page with: ADMN and MD signatures on [DATE] and DON, ADON, Payroll, BOM, Housekeeping, Maintenance Director, Medical Records, Nutrition Services, Rehab Services Director, Social Service, and Activity Director signatures on [DATE]. The ADMIN was informed that the Immediate Jeopardy was removed on [DATE] at 3:18 PM. The facility remained out of compliance at a scope of isolated with no actual harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems that were put into place.