**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform resident's physician when a resident experienced increased shortness of breath for 1 of 1 resident (CR #1) reviewed for physician notification. LVN A failed to notify MD A in a timely manner on 8/5/23 when CR #1 was having increased shortness of breath. This caused a delay in CR #1 going to the hospital for to respiratory distress. RN A consulted with the NP but not the physician when CR#1 was having a change in condition An Immediate Jeopardy (IJ) situation was identified on 9/15/2023 9:10 am. While the IJ was removed on 09/19/2023 at 1:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for inadequate or delayed treatment and interventions. Findings included: Record review of CR #1's undated face sheet, revealed an [AGE] year-old male admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing problems), acute respiratory failure with hypoxia (not enough oxygen in the body/blood), sepsis (infection involving the whole body), congestive heart failure (heart failure that causes back up of fluid in the lungs and legs) and atrial fibrillation (abnormal heart rhythm). Record review of CR #1's medical record on 8/6/23, revealed an Minimum Data Set ((MDS) an assessment tool) had not been completed yet. Record review of CR #1's baseline care plan, initiated on 7/29/23, revealed the resident was at risk for falls r/t neuropathy (nerve pain), obesity, CKD 3 (kidneys are not working properly), AFIB, hypoxia (not getting enough oxygen), hypotension (low blood pressure), SOB, CHF, depression, HTN (high blood pressure), COPD, sepsis, Anemia (low iron in the blood), joint pain, use of supplemental O2, use of opiate pain medication, use of diuretics (medications that take fluid out of the body), use of antidepressants. Record review of CR #1's medical records revealed previous hospital records from 7/22/23 that indicated he was hospitalized for SOB and CHF. Record review of CR #1's provider notes from 8/4/23 at 2:17pm revealed Per pt, doing ok and some sob still on 4L NC at this time. Appeared comfortable .no edema [swelling] noted in bil. [both sides] Lower ext, no other overnight episode reported evaluated by NP A. Record review of CR #1's medical record on 8/6/23 revealed the following orders from MD A: - Oxygen at 4lpm via NC ordered on 7/28/23. - Albuterol Sulfate HFA Inhalation Aerosol Solution mcg/act, 1 puff inhale PO Q6hr PRN for wheezing, ordered on 7/31/23. - Arformoterol Tartrate Inhalation Nebulization Solution 15 mcg/2ml, 2ml inhale PO via nebulizer QD for COPD, ordered on 7/28/23. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhale PO Q12hr for COPD, ordered on 7/28/23. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhale PO Q4hr PRN for SOB related to COPD, ordered on 8/2/23. Record review of CR #1's medical record revealed a Skilled Nursing Evaluation performed on 8/4/23 by LVN B, that revealed the resident had no difficulty breathing, had clear lungs, had a cough with effective airway and retained secretions, and was on respiratory antibiotics. Record review of CR #1's August 2023 MAR revealed, on 8/4/23 he had clear lung sounds at 9:00am before and after nebulizer treatments, assessed by RN B. He also had clear lung sounds before and after nebulizer treatments at 9:00pm, assessed by RN A. On 8/5/23 at 9:00am CR #1 had wheezy lung sounds before and after nebulizer treatments, assessed by LVN A. Record review of CR #1's August 2023 MAR revealed on 8/5/23 he received the following medications: - Arformoterol Tartrate Inhalation 15mcg/2ml, 2ml inhaled via nebulizer at 9:00am given by LVN A. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhaled at 9:00am given by LVN A. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled at 6:25pm given by RN A. Record review of CR #1's medical record revealed on 8/5/23 Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act, 1 puff Q6hr PRN wheezing, AND Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled Q4hr PRN SOB, were not given by LVN A. Record review of CR #1's medical record revealed a progress note from RN A on 8/5/23 at 6:20pm that stated, Seen patient sitting at bedside having SOB, difficulty speaking, using accessory muscles [muscles other than the diaphragm that indicate labored breathing] and breathing through his mouth, heard crackles, gave PRN Ipratropium-Albuterol inhalation- not working - still having respi distress; checked vital signs BP 128/72 PR 112 Temp 98.2 and O2 sat at 97% with O2 at 4LPM via NC; reported to NP as patient said he was having this the whole day; [NP A] sent message to send patient out to hospital due to worsening respi distress; called 911, informed DON, and family since [family] is in the room. Called [name of the hospital] and gave report. Ambulance came and left with patient at left at 1910 [7:10pm]. Record review of CR #1's medical record revealed an administration note on 8/5/23 at 6:25pm by RN A that stated, she gave Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3ml. She also stated, patient complained of SOB, heard crackles, unable to speak properly, breathing to his mouth [breathing through his mouth], vital signs checked; 128/72; pulse 113; 97% O2 sat via 4LNC. Record review of CR #1's EMS Transport Report from 8/5/23 revealed they arrived at the facility at 6:57pm. According to the report, his primary symptom was respiratory distress. Per the report at 7:01pm, Pt was found to have an increased respiratory effort. Lung sounds were found to be diminished in the lower lobes bilaterally and rhonchi [continuous gurgling/bubbling sounds heard during inhalation and exhalation] in the apexes [very top] bilaterally. At 7:05pm EMS placed a non-rebreather mask on the resident and increased his oxygen to 10LPM and Pt respiratory effort improved once on the non-rebreather mask. According to the EMS narrative report taken by EMS #1 They found the patient sitting upright in his bed with a nebulizer mask on in the process of finishing a treatment. The patient was awake, alert, and appeared to have an increased effort for respirations. The patient's [family] reported she arrived at the facility about 4:00pm today. She stated she found him having difficulty breathing. She stated he could only get one word out at a time. The patient's [family] stated she had to make a scene to have the nursing staff come in to treat him. The [family] stated he was supposed to be getting nebulizer treatments throughout the day and they had not done one until she arrived. She stated he did not appear to be getting any better and the facility staff did not want to call for EMS . In an interview with family at the hospital on 8/6/23 at 3:44pm, she revealed staff were not listening to CR #1's lungs regularly on 8/5/23, to know if he needed his neb treatments. She said that CR #1 had bad COPD and was not getting his PRN neb treatments regularly throughout the day on 8/5/23. She said that CR #1 knew when his COPD was flaring up and when he needed his neb treatments, but staff were not giving them to him, so when she got to the facility on 8/5/23 at around 4:00pm he was gasping for air, pale, and making guggling sounds. LVN B, a nurse from another hall came in the room to assess him, and the family member asked her to have an MD come assess CR #1 or to send him to the hospital. The family member stated LVN B told them that he did not need to go to the hospital. CR #1 tried to explain how he was feeling and LVN B cut him off and said, Listen to me! The family member said she was very rude, demanding, and did not want to listen to anything they had to say. The family member also said that LVN B told them he was having problems from drinking/eating lying down. The family member said that was ridiculous and they were never sent to the hospital. The family member said finally RN A nurse came and listened to what they were saying and called the MD for an ER transfer order, and they were sent to the hospital. The family member stated RN A was the only one who listened to them. In an interview on 8/6/23 at 4:30pm with the Charge Nurse at the hospital, she said the admitting diagnosis for CR #1 was shortness of breath and he would be there for a few days, getting diuretics (water pills), neb treatments, steroids (helps with inflammation), and antibiotics. In an interview on 8/6/23 at 6:27pm with RN A she said she was the nurse who came on shift at 6pm on 8/5/23. She took report from LVN A and he said that CR #1 had been requesting to go to the hospital all day, so she saw him first at about 6:30pm. She said she took his vital signs, and they were ok, but he appeared to be physically having a hard time breathing. She stated he was using his accessory muscles to breathe, and he looked uncomfortable. She said she gave him some neb treatments, but they did not work, so she called the MD and told her that CR #1 had been breathing like that all day. The MD said to send CR #1 to the hospital. RN A was not sure why LVN A did not send CR #1 to the hospital. She said if the resident/family requests to go to the hospital, they do not tell them no, but staff would perform a nursing assessment first to see what was wrong and if the resident really needed to go to the hospital. She said, then they call the MD with the assessment findings, and it was up to the MD if they wanted to send the resident or not. RN A stated the family had mentioned to her that no one was helping them (CR #1 and family) the whole day until she arrived, and she was the first one to help them. Record review of CR #1's medical record on 8/5/23 revealed no documentation from LVN A that he contacted the MD or the NP. There was no documentation of an assessment of CR #1's lungs, or vitals taken around the time CR #1 complained of increased shortness of breath. In an interview on 8/6/23 at 3:12pm with EMS A he revealed when he arrived in CR #1's room it was evident he was struggling to breathe. He said CR #1 had increased respirations, belly breathing, and could only say a few words at a time without stopping to catch his breath. He stated the family member had told him she got there at about 4:00pm and had to really fight for CR #1 to get neb treatments. CR #1 was on his 2nd neb treatment when EMS arrived. Record review of CR #1's hospital records from 8/6/23, revealed he was diagnosed with respiratory failure, COPD exacerbation, and CHF exacerbation. In an interview on 8/17/23 at 10:23am LVN A stated CR #1 was congested when he assessed his lungs in the morning. He remembered that CNA A came and told him that CR #1 had eaten something, and it went in the wrong tube. He said CR #1 started complaining of increased SOB around 5:00pm and when he assessed his lungs he was still just as congested as he was in the morning, and his vitals were normal. He stated the family wanted him to go to the hospital, so he called the MD. He said the MD called back and said he was not taking care of the resident and for him to call his NP. He said he then called the NP and she said to send the resident to the hospital. LVN A said by the time the NP said to send the resident to the hospital, it was shift change already. He stated CR #1 did not appear to be working harder to breathe and looked the same. He said he did not remember if he gave the resident neb treatments but knew he was already on Levaquin (antibiotic) and had other meds ordered. LVN A also did not remember if he had documented his phone call, assessment, or vitals. He did not know why he did not document them, he said he must have forgotten. In an interview on 8/17/23 at 2:10pm with NP A she stated she was notified about CR #1's condition by the nurse via text at 6:23pm and she replied via text to send him to the hospital at 6:27pm. She said she did not talk to anyone else regarding CR #1 prior to that date/time. A message was left for MD A on 8/17/23 at 11:09am, but he did not call back. In an interview with the DON on 8/17/23 at 3:06pm he revealed it was his expectation of staff to assess the resident, give PRN meds, and reach out to the MD when a resident came to the facility, newly discharged from the hospital with COPD exacerbation, and had shortness of breath. The DON said he assessed the nurses for competency and provided yearly competencies as well as in-services/trainings. He stated that LVN A was PRN, new to the facility, and worked at a couple other places as well. The DON stated that a change in condition would be anything outside of the normal for the resident. He said if the resident had COPD, then it would be anything that was not normal for him, which would include increased shortness of breath. He also stated it was his expectation that if there was a change in condition that a progress note be filled out, an assessment of the resident, vitals, what treatment was given, and when the provider was spoken to and what they said should also be documented. The DON stated he expected the nurses to provide a focused assessment for the particular concern at hand. He said if the resident complained of being SOB, he expected a focused respiratory assessment, to give any medications available for that concern, and then call the MD if the resident did not improve. He stated the same would apply if the resident complained but everything was normal with the resident. The DON stated the nurse should contact the MD immediately if the meds did not help. He also stated the 5:00pm nurse should have evaluated, provided treatment, and called the MD before change of shift, and this incident would not be something to hand off to the next shift. The DON did not think LVN A did what he was supposed to do in the situation and should have called the MD himself instead of passing it off to the next shift. The DON also said LVN A should have documented everything that he did and the assessment and vitals of the resident. Record review of the facility's Policy and Procedure on Acute Condition Changes- Clinical Protocol (Revised March 2018) read in part: .2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs .d. Level of consciousness .g. Onset, duration, severity .3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident .and how to communicate these changes to the Nurse .5. The physician and nursing staff will review the details of any recent hospitalizations and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having addition complications .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician .8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or practitioner) will respond in a timely manner to notification of problems or changes in condition and status .10. The nurse and physician will discuss and evaluate the situation .1. The physician will help identify and authorize appropriate treatments .3. If it is decided .the physician will authorize transfer to an acute hospital, Emergency Room, or another appropriate setting .1. The staff will monitor and document the resident's progress and responses to treatment . Record review of the facility's Policy and Procedure for Chronic Obstructive Pulmonary Disease (COPD)- Clinical Protocol (Revised November 2018) read in part: .2. In addition, the nurse shall assess and document/report the following: a. Vital signs (including detailed descriptions of respirations) b. Full lung assessment (including sounds of wheezing, sputum production) .d. Pulse oximetry result e. Onset, duration, frequency, severity . 3. The physician and staff will identify individuals with risk factors for developing COPD or for exacerbation of existing COPD .7. The physician will identify individuals with complications of COPD; for example, cor pulmonale [alteration in structure/function of the right ventricle of the heart caused by respiratory system, causing pulmonary hypertension], arrhythmia [irregular heart rhythm] or lethargy [very tired and hard to wake up], or confusion due to hypoxia .3. The physician and staff will identify relevant elements of the care plan; for example, what symptoms to expect (dyspnea, cough, fever, progressive activity intolerance, etc.), how often and what to monitor, when to report findings to the physician .4. Key objectives of COPD management include: a. Minimize disease progression b. Relieve symptoms .e. Prevent and treat exacerbations .11. The physician and staff will identify and manage complications of COPD, such as acute infections, hypoxia .and respiratory failure .12. The staff and physician will identify and treat acute exacerbations of COPD; for example, recognizing and reporting when an individual with COPD has a change in function or activity tolerance, increased dyspnea [trouble breathing], additional sputum production, cough, increasing lethargy or confusion, increased wheezing, increased respiratory or heart rates .1. The staff and physician will monitor the progress of individuals with COPD, including ongoing evaluation and documentation of signs and symptoms and condition changes . Record review of the facility's Policy and Procedure for Change in a Resident's Condition or Status (Revised February 2021) read in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician of physician on call when there has been a(n): .d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly .i. Specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status 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 details observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . On 9/15/2023 9:10 a.m. an Immediate Jeopardy (IJ) was identified. The Administrator was notified and provided the IJ template on 9/15/2023 9:10 a.m.; and a POR was requested at that time. After several revisions, the POR submitted by the Administrator was accepted on 9/19/2023 at 3:30 pm. PLAN OF REMOVAL The DON, ADON in-serviced all licensed staff, via live in-service, on observing for changes of condition on September 15th, continuing through September 18, 2023. The training included when to notify MD of a change of condition. All nurses should inform the MD after the following steps have been taken. 1. A nursing assessment has been completed. 2. PRN medications are administered as ordered. 3. A reassessment is completed and determined that interventions were not effective. 4. Call MD with information obtained and carry out any new orders provided. In the instance a patient or family member was requesting to go to the hospital the following steps should be taken: 1. Reassure patient and family 2. Follow nursing process and complete a nursing assessment 3. Provide PRN medications as ordered 4. Reassess patient and determine if interventions are effective 5. Call MD with information and carry out any new orders provided In the instance when the MD does not answer in a prompt manner, (within 2 calls), the nurse should call the Medical Director for further instructions. If the patient was unstable the nurse should call 911 immediately. This would include abnormal vital signs outside of the patients previously assessed normal, for example a sustained oxygen saturation of 85% or lower with no success increasing after oxygen therapy. On 9/15/2023, a chart audit for recent significant changes of condition was completed by management nurses. All changes were reported to the MD's. Current patients with the above conditions were assessed by licensed nurses. Assessments included blood pressure, pulse, respirations at rest, respirations with activity, temperature, lung sounds and oxygen saturations. In addition, return demonstrations were observed by the assigned nurse managers to ensure competency. There were no incidents when prn respiratory treatments were required, based on nursing assessment. Those assessments were placed in the appropriate medical chart upon completion. All non-PRN licensed nurses were trained by September 19th, 2023. Staff will have had training before their next scheduled shift or will not be allowed to work the floor until said training is completed. MONITORING During IJ implementation dates 9/15/2023-9/19/2023, investigation, interview and monitoring for Notify of Changes, this surveyor observed nursing staff doing their work, interviewed nurses on day and night shift, interviewed other staff members regarding and new and recent trainings by, computer, licensed in person in-service. 12 of 12 nursing staff were able to verbalize and verify new and reinforced training regarding changes of condition, SBAR documentation, Oxygen therapy, respiratory medication, following orders, PRN medications and documentation of refusal of medications. Record review of Training 9/15/2023-9/19/2023 included: call the doctor or the nurse practitioner, and if the doctor or nurse practitioner do not respond timely or appropriately when the patients change of condition is reported- they should report to DON/ADON and the Medical Director if ADON/DON not available. The training consisted of specifically observing acute changes in patients with COPD, respiratory infections and other diseases of the lungs. Patients were assessed with COPD, respiratory infections by licensed nurses. Assessments included blood pressure, pulse, respiration at rest, respiration with activity, temperature, lung sounds and, oxygen saturation. Nurses report in the event family member or resident request to be sent to hospital, they will inquire as to why, perform assessment, SBAR, contact medical doctor or nurse practitioner, explain to the doctor/nurse practitioner what the resident is requesting, the vital signs, signs and symptoms they observed, receive orders, follow orders, in the event no new orders are given, DON will be contacted and medical director may be contacted. Interviews between 9/15/2023-9/19/2023, 12 of 12 Nurses were able to verbalize: signs and symptoms of COPD, signs and symptoms of COPD, ineffective breathing pattern assessment, ineffective breathing pattern interventions, activity intolerance assessment, activity intolerance interventions, deficient knowledge assessment, deficient knowledge interventions, respiratory assessment, oxygen administration, nebulizer therapy, small volume, and proper documentation. Record Reviews between 9/15/2023-9/19/2023, were performed regarding the training and monitoring to be done by management when and found to be compliant with standards of care. Residents were interviewed between 9/15/2023-9/19/2023 and were pleased with the care received by all staff members in the facility and reported they got their medications timely and when they asked for prn medications, the prn medications were given timely. Plan of Removal (POR) on 9/19/2023 at 3:30 pm. The Administrator, DON were informed the Immediate Jeopardy (IJ) was removed on 09/19/2023 at 1:09 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the 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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 resident of 1 (CR #1) reviewed for quality of care. The facility failed to adequately assess and provide PRN respiratory treatments to CR #1 on 8/5/23 when he had increased shortness of breath, which led to respiratory distress and hospitalization. CR #1 was admitted to the hospital for shortness of breath. An Immediate Jeopardy (IJ) situation was identified on 9/15/2023 9:10 am. While the IJ was removed on 09/19/2023 at 1:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening shortness of breath and potential respiratory distress. Findings included: Record review of CR #1's undated face sheet, revealed an [AGE] year-old male admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing problems), acute respiratory failure with hypoxia (not enough oxygen in the body/blood), sepsis (infection involving the whole body), congestive heart failure (heart failure that causes back up of fluid in the lungs and legs) and atrial fibrillation (abnormal heart rhythm). Record review of CR #1's medical record on 8/6/23, revealed an MDS had not been completed yet. Record review of CR #1's baseline care plan, initiated on 7/29/23, revealed the resident was at risk for falls r/t neuropathy, obesity, CKD 3, AFIB, hypoxia, hypotension, SOB, CHF, depression, HTN, COPD, sepsis, Anemia, joint pain, use of supplemental O2, use of opiate pain medication, use of diuretics, use of antidepressants. Record review of CR #1's medical records revealed previous hospital records from 7/22/23 that indicated he was hospitalized for SOB and CHF. Record review of CR #1's provider notes from 8/4/23 at 2:17pm revealed Per pt, doing ok and some sob still on 4L NC at this time. Appeared comfortable .no edema [swelling] noted in bil. [both sides] Lower ext, no other overnight episode reported evaluated by NP A. Record review of CR #1's medical record on 8/6/23 revealed the following orders from MD A: - Oxygen at 4lpm via NC ordered on 7/28/23. - Albuterol Sulfate HFA Inhalation Aerosol Solution mcg/act, 1 puff inhale PO Q6hr PRN for wheezing, ordered on 7/31/23. - Arformoterol Tartrate Inhalation Nebulization Solution 15 mcg/2ml, 2ml inhale PO via nebulizer QD for COPD, ordered on 7/28/23. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhale PO Q12hr for COPD, ordered on 7/28/23. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhale PO Q4hr PRN for SOB related to COPD, ordered on 8/2/23. Record review of CR #1's medical record revealed a Skilled Nursing Evaluation performed on 8/4/23 by LVN B, that revealed the resident had no difficulty breathing, had clear lungs, had a cough with effective airway and retained secretions, and was on respiratory antibiotics. Record review of CR #1's August 2023 MAR revealed, on 8/4/23 he had clear lung sounds at 9:00am before and after nebulizer treatments, assessed by RN B. He also had clear lung sounds before and after nebulizer treatments at 9:00pm, assessed by RN A. On 8/5/23 at 9:00am CR #1 had wheezy lung sounds before and after nebulizer treatments, assessed by LVN A. Record review of CR #1's August 2023 MAR revealed on 8/5/23 he received the following medications: - Arformoterol Tartrate Inhalation 15mcg/2ml, 2ml inhaled via nebulizer at 9:00am given by LVN A. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhaled at 9:00am given by LVN A. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled at 6:25pm given by RN A. Record review of CR #1's medical record revealed on 8/5/23 Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act, 1 puff Q6hr PRN wheezing, AND Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled Q4hr PRN SOB, were not given by LVN A. Record review of CR #1's medical record revealed a progress note from RN A on 8/5/23 at 6:20pm that stated, Seen patient sitting at bedside having SOB, difficulty speaking, using accessory muscles [using muscles other than diaphragm which indicates labored breathing] and breathing through his mouth, heard crackles, gave PRN Ipratropium-Albuterol inhalation- not working - still having respi distress; checked vital signs BP 128/72 PR 112 Temp 98.2 [F] and O2 sat at 97% with O2 at 4LPM via NC; reported to NP as patient said he was having this the whole day; [NP A] sent message to send patient out to hospital due to worsening respi distress; called 911, informed DON, and family since [family] is in the room. Called [name of the hospital] and gave report. Ambulance came and left with patient at left at 1910. [7:10pm] Record review of CR #1's medical record revealed an administration note on 8/5/23 at 6:25pm by RN A that stated, she gave Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3ml. She also stated, patient complained of SOB, heard crackles, unable to speak properly, breathing to his mouth [breathing through his mouth], vital signs checked; 128/72; pulse 113; respirations 16, 97% O2 sat via 4LNC. Record review of CR #1's EMS Transport Report from 8/5/23 revealed they arrived at the facility at 6:57pm. According to the report, his primary symptom was respiratory distress. Per the report at 7:01pm, Pt was found to have an increased respiratory effort. Lung sounds were found to be diminished in the lower lobes bilaterally and rhonchi rhonchi [continuous gurgling/bubbling sounds heard during inhalation and exhalation] in the apexes [very top] bilaterally. At 7:02pm CR #1's vitals were blood pressure: 124/78, heart rate: 107, respirations: 28, and oxygen saturation 93%. At 7:05pm EMS placed a non-rebreather mask on the resident and increased his oxygen to 10LPM and Pt respiratory effort improved once on the non-rebreather mask. According to the EMS narrative report taken by EMS #1 They found the patient sitting upright in his bed with a nebulizer mask on in the process of finishing a treatment. The patient was awake, alert, and appeared to have an increased effort for respirations. The patient's [family] reported she arrived to the facility about 4:00pm today. She stated she found him having difficulty breathing. She stated he could only get one word out at a time. The patient's [family] stated she had to make a scene to have the nursing staff come in to treat him. The [family] stated he was supposed to be getting nebulizer treatments throughout the day and they had not done one until she arrived. She stated he did not appear to be getting any better and the facility staff did not want to call for EMS . In an interview with family at the hospital on 8/6/23 at 3:44pm, she revealed staff were not listening to CR #1's lungs regularly on 8/5/23 to know if he needed his neb treatments. She said that CR #1 had bad COPD and was not getting his PRN neb treatments regularly throughout the day on 8/5/23. She said that CR #1 knew when his COPD was flaring up and when he needed his neb treatments, but staff were not giving them to him, so when she got to the facility on 8/5/23 at around 4:00pm he was gasping for air, pale, and making guggling sounds. LVN B, a nurse from another hall came in the room to assess him, and the family member asked her to have an MD come assess CR #1 or to send him to the hospital. The family member stated LVN B told them that he did not need to go to the hospital. CR #1 tried to explain how he was feeling and LVN B cut him off and said, Listen to me! The family member said she was very rude, demanding, and did not want to listen to anything they had to say. The family member also said that LVN B told them he was having problems from drinking/eating lying down. The family member said that was ridiculous and they were never sent to the hospital. The family member said finally a RN A came and listened to what they were saying and called the MD for an ER transfer order, and they were sent to the hospital. The family member stated RN A was the only one who listened to them. In an interview with CR #1 on 8/6/23 at 3:44pm, he confirmed that he had increased shortness of breath on 8/5/23 and was telling the staff there was something wrong with him and he wanted to be sent to the hospital, but they were not listening to him. In an interview on 8/6/23 at 4:30pm with the Charge Nurse at the hospital, she said the admitting diagnosis for CR #1 was shortness of breath and he would be there for a few days getting diuretics (water pills), steroids (helps with inflammation), antibiotics, and neb treatments. In an interview on 8/6/23 at 6:27pm with RN A she said she was the nurse who came on shift at 6pm on 8/5/23. She took report from LVN A and he said that CR #1 had been requesting to go to the hospital all day, so she saw him first at about 6:30pm. She said she took his vital signs, and they were ok, but he appeared to be physically having a hard time breathing. She stated he was using his accessory muscles to breathe, and he looked uncomfortable. She said she gave him some neb treatments, but they did not work, so she called the MD and told her that CR #1 had been breathing like that all day. The MD said to send CR #1 to the hospital. RN A was not sure why LVN A did not send CR #1 to the hospital. She said if the resident/family requests to go to the hospital, they do not tell them no, but staff would perform a nursing assessment first to see what was wrong and if the resident really needed to go to the hospital. She said, then they called the MD with the assessment findings, and it was up to the MD if they wanted to send the resident or not. RN A stated the family had mentioned to her that no one was helping them (CR #1 and the family) the whole day until she arrived, and she was the first one to help them. Record review of CR #1's medical record on 8/5/23 revealed no documentation from LVN A that he contacted the MD or the NP. There was no documentation of an assessment of CR #1's lungs, or vitals taken around the time CR #1 complained of increased shortness of breath. In an interview on 8/6/23 at 3:12pm with EMS A he revealed when he arrived in CR #1's room it was evident he was struggling to breathe. He said CR #1 had increased respirations, belly breathing, and could only say a few words at a time without stopping to catch his breath. He stated the family member had told him she got there at about 4:00pm and had to really fight for CR #1 to get neb treatments. CR #1 was on his 2nd neb treatment when EMS arrived. Record review of CR #1's hospital records from 8/6/23, revealed he was diagnosed with respiratory failure, COPD exacerbation, and CHF exacerbation. In an interview with LVN B on 8/8/23 at 12:12pm, she said she was not CR #1's nurse on 8/5/23 but went and assessed him to help out. She said the family and the resident were concerned about his breathing and wanted him to go to the hospital. LVN B informed the family/resident that she would need to call the MD first to get an order and it ay take a while because it was the weekend. She did see that he was using accessory muscles while breathing, but said he always did. LVN B did not think CR #1 was in respiratory distress. In an interview on 8/17/23 at 10:23am LVN A stated CR #1 was congested when he assessed his lungs in the morning. He remembered that CNA A came and told him that CR #1 had eaten something, and it went in the wrong tube. He said CR #1 started complaining of increased SOB around 5:00pm and when he assessed his lungs he was still just as congested as he was in the morning, and his vitals were normal. LVN A stated he did not feel CR #1 had a change in condition because his lungs sounded the same as they had in the morning and his vitals were stable. He did not feel the resident was serious enough to call 911, so he called the MD instead. He stated the family wanted him to go to the hospital, so he called the MD. He stated the protocol was the nurse assessed the resident and then called the MD with the assessment findings and it was up to the MD to decide if they wanted to send the resident to the hospital or not. He said the MD called back and said he was not taking care of the resident and for him to call his NP. He said he then called the NP and she said to send the resident to the hospital. LVN A said by the time the NP said to send the resident to the hospital, it was shift change already. He stated CR #1 did not appear to be working harder to breathe and looked the same. He said he did not remember if he gave the resident neb treatments but knew he was already on Levaquin (antibiotic) and had other meds ordered. LVN A also did not remember if he had documented his phone call, assessment, or vitals. He did not know why he did not document them, he said he must have forgotten. In an interview on 8/17/23 at 2:10pm with NP A she stated she was notified about CR #1's condition by the nurse via text at 6:23pm and she replied via text to send him to the hospital at 6:27pm. She said she did not talk to anyone else regarding CR #1 prior to that date/time. A message was left for MD A on 8/17/23 at 11:09am, but he did not call back. In an interview with the DON on 8/17/23 at 3:06pm he revealed it was his expectation of staff to assess the resident, give PRN meds, and reach out to the MD when a resident came to the facility, newly discharged from the hospital with COPD exacerbation, and had shortness of breath. The DON said he assessed the nurses for competency and provided yearly competencies as well as in-services/trainings. He stated that LVN A was PRN, new to the facility, and worked at a couple other places as well. The DON stated that a change in condition would be anything outside of the normal for the resident. He said if the resident had COPD, then it would be anything that was not normal for him, which would include increased shortness of breath. He also stated it was his expectation that if there was a change in condition that a progress note be filled out, an assessment of the resident, vitals, what treatment was given, and when the provider was spoken to and what they said should also be documented. The DON stated he expected the nurses to provide a focused assessment for the particular concern at hand. He said if the resident complained of being SOB, he expected a focused respiratory assessment, to give any medications available for that concern, and then call the MD if the resident did not improve. He stated the same would apply if the resident complained but everything was normal with the resident. The DON stated the nurse should contact the MD immediately if the meds did not help. He also stated the 5:00pm nurse should have evaluated, provided treatment, and called the MD before change of shift, and this incident would not be something to hand off to the next shift. The DON did not think LVN A did what he was supposed to do in the situation and should have called the MD himself instead of passing it off to the next shift. The DON also said LVN A should have documented everything that he did and the assessment and vitals of the resident. Record review of the facility's Policy and Procedure for Chronic Obstructive Pulmonary Disease (COPD)- Clinical Protocol (Revised November 2018) read in part: .2. In addition, the nurse shall assess and document/report the following: a. Vital signs (including detailed descriptions of respirations) b. Full lung assessment (including sounds of wheezing, sputum production) .d. Pulse oximetry result e. Onset, duration, frequency, severity . 3. The physician and staff will identify individuals with risk factors for developing COPD or for exacerbation of existing COPD .7. The physician will identify individuals with complications of COPD; for example, cor pulmonale, arrhythmia or lethargy, or confusion due to hypoxia .3. The physician and staff will identify relevant elements of the care plan; for example, what symptoms to expect (dyspnea, cough, fever, progressive activity intolerance, etc.), how often and what to monitor, when to report findings to the physician .4. Key objectives of COPD management include: a. Minimize disease progression b. Relieve symptoms .e. Prevent and treat exacerbations .11. The physician and staff will identify and manage complications of COPD, such as acute infections, hypoxia .and respiratory failure .12. The staff and physician will identify and treat acute exacerbations of COPD; for example, recognizing and reporting when an individual with COPD has a change in function or activity tolerance, increased dyspnea, additional sputum production, cough, increasing lethargy or confusion, increased wheezing, increased respiratory or heart rates .1. The staff and physician will monitor the progress of individuals with COPD, including ongoing evaluation and documentation of signs and symptoms and condition changes . Record review of the facility's Policy and Procedure for Administering Medications Through a Small Volume (Handheld) Nebulizer (Revised October 2016) read in part: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .2, If the resident suffers from Chronic Obstructive Pulmonary Disease (COPD), refer to the Chronic Obstructive Pulmonary Disease (COPD), Clinical Protocol in addition to this procedure .5. Position the resident in semi-Fowler's position. 6. Obtain baseline pulse, respiratory rate, and lung sounds .9. Dispense medication into nebulizer cup .13. Turn on the nebulizer and check the outflow port for visible mist. 14. Ask the resident to hold the mouthpiece gently between his/her lips (or apply face mask). 15. Encourage the resident to take a deep breath, pause briefly and then exhale normally. 16. Encourage the resident to repeat the above breathing pattern until the medication is completely nebulized, or until the designated time of treatment has been reached. 17. Remain with the resident for the treatment. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment .21. Tap the nebulizer cup occasionally to ensure release of droplets from the sides of the cup. 22. Encourage the resident to cough and expectorate as needed. 23. Administer therapy until medication is gone .26. Obtain post-treatment pulse, respiratory rate and lung sounds .The following information should be recorded in the resident's medical record. 1. The name, title and initials of the person administering the treatment. 2. The date, time and length of treatment .3. The type and amount of medication administered .4. The type and source of gas. 5. Pulse, respiratory rate and lung sounds before and after the treatment. 6. Pulse during treatment. 7. Amount and characteristics of sputum production. 8. The resident's tolerance of the treatment. 9. Any adverse effects of the medication and/or treatment and physician notification . On 9/15/2023 9:10 a.m. an Immediate Jeopardy (IJ) was identified. The Administrator was notified and provided the IJ template on 9/15/2023 9:10 a.m.; and a POR was requested at that time. After several revisions, the POR submitted by the Administrator was accepted on 9/19/2023 at 3:30 pm. PLAN OF REMOVAL The DON, ADON in-serviced all licensed staff, via live in-service, on observing for changes of condition on September 15th, continuing through September 18, 2023. The training included when to notify MD of a change of condition. All nurses should inform the MD after the following steps have been taken. 1. A nursing assessment has been completed. 2. PRN medications are administered as ordered. 3. A reassessment is completed and determined that interventions were not effective. 4. Call MD with information obtained and carry out any new orders provided. In the instance a patient or family member was requesting to go to the hospital the following steps should be taken: 1. Reassure patient and family 2. Follow nursing process and complete a nursing assessment 3. Provide PRN medications as ordered 4. Reassess patient and determine if interventions are effective 5. Call MD with information and carry out any new orders provided In the instance when the MD does not answer in a prompt manner, (within 2 calls), the nurse should call the Medical Director for further instructions. If the patient was unstable the nurse should call 911 immediately. This would include abnormal vital signs outside of the patients previously assessed normal, for example a sustained oxygen saturation of 85% or lower with no success increasing after oxygen therapy. On 9/15/2023, a chart audit for recent significant changes of condition was completed by management nurses. All changes were reported to the MD's. Current patients with the above conditions were assessed by licensed nurses. Assessments included blood pressure, pulse, respirations at rest, respirations with activity, temperature, lung sounds and oxygen saturations. In addition, return demonstrations were observed by the assigned nurse managers to ensure competency. There were no incidents when prn respiratory treatments were required, based on nursing assessment. Those assessments were placed in the appropriate medical chart upon completion. All non-PRN licensed nurses were trained by September 19th, 2023. Staff will have had training before their next scheduled shift or will not be allowed to work the floor until said training is completed. MONITORING During IJ implementation dates 9/15/2023-9/19/2023, investigation, interview and monitoring for Notify of Changes, this surveyor observed nursing staff doing their work, interviewed nurses on day and night shift, interviewed other staff members regarding and new and recent trainings by, computer, licensed in person in-service. 12 of 12 nursing staff were able to verbalize and verify new and reinforced training regarding changes of condition, SBAR documentation, Oxygen therapy, respiratory medication, following orders, PRN medications and documentation of refusal of medications. Record review of Training between 9/15/2023-9/19/2023 included: call the doctor or the nurse practitioner, and if the doctor or nurse practitioner do not respond timely or appropriately when the patients change of condition is reported- they should report to DON/ADON and the Medical Director if ADON/DON not available. The training consisted of specifically observing acute changes in patients with COPD, respiratory infections and other diseases of the lungs. Patients were assessed with COPD, respiratory infections by licensed nurses. Assessments included blood pressure, pulse, respiration at rest, respiration with activity, temperature, lung sounds and, oxygen saturation. Nurses report in the event family member or resident request to be sent to hospital, they will inquire as to why, perform assessment, SBAR, contact medical doctor or nurse practitioner, explain to the doctor/nurse practitioner what the resident is requesting, the vital signs, signs and symptoms they observed, receive orders, follow orders, in the event no new orders are given, DON will be contacted and medical director may be contacted. Interviews between 9/15/2023-9/19/2023, 12 of 12 Nurses were able to verbalize: signs and symptoms of COPD, signs and symptoms of COPD, ineffective breathing pattern assessment, ineffective breathing pattern interventions, activity intolerance assessment, activity intolerance interventions, deficient knowledge assessment, deficient knowledge interventions, respiratory assessment, oxygen administration, nebulizer therapy, small volume, and proper documentation. Record Reviews between 9/15/2023-9/19/2023, were performed regarding the training and monitoring to be done by management when and found to be compliant with standards of care. Residents were interviewed between 9/15/2023-9/19/2023 and were pleased with the care received by all staff members in the facility and reported they got their medications timely and when they asked for prn medications, the prn medications were given timely. Plan of Removal (POR) on 9/19/2023 at 3:30 pm. The Administrator, DON were informed the Immediate Jeopardy (IJ) was removed on 09/19/2023 at 1:09 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the 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 licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 nurse (LVN A) reviewed for nursing services. LVN A failed to have required documentation of competencies on change of condition. An Immediate Jeopardy (IJ) situation was identified on 9/15/2023 9:10 am. While the IJ was removed on 09/19/2023 at 1:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for inadequate or delayed treatment and interventions. Findings included: Record review of CR #1's undated face sheet, revealed an [AGE] year-old male admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing problems), acute respiratory failure with hypoxia (not enough oxygen in the body/blood), sepsis (infection involving the whole body), congestive heart failure (heart failure that causes back up of fluid in the lungs and legs) and atrial fibrillation (abnormal heart rhythm). Record review of CR #1's medical record on 8/6/23, revealed an MDS had not been completed yet. Record review of CR #1's baseline care plan, initiated on 7/29/23, revealed the resident was at risk for falls r/t neuropathy (nerve pain), obesity, CKD 3 (kidneys are not working properly), AFIB, hypoxia (not getting enough oxygen), hypotension (low blood pressure), SOB, CHF, depression, HTN (high blood pressure), COPD, sepsis, Anemia (low iron in the blood), joint pain, use of supplemental O2, use of opiate pain medication, use of diuretics (medications that take fluid out of the body), use of antidepressants. Record review of CR #1's medical records revealed previous hospital records from 7/22/23 that indicated he was hospitalized for SOB and CHF. Record review of CR #1's provider notes from 8/4/23 at 2:17pm revealed Per pt, doing ok and some sob still on 4L NC at this time. Appeared comfortable .no edema [swelling] noted in bil. [both sides] Lower ext, no other overnight episode reported evaluated by NP A. Record review of CR #1's medical record on 8/6/23 revealed the following orders from MD A: - Oxygen at 4lpm via NC ordered on 7/28/23. - Albuterol Sulfate HFA Inhalation Aerosol Solution mcg/act, 1 puff inhale PO Q6hr PRN for wheezing, ordered on 7/31/23. - Arformoterol Tartrate Inhalation Nebulization Solution 15 mcg/2ml, 2ml inhale PO via nebulizer QD for COPD, ordered on 7/28/23. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhale PO Q12hr for COPD, ordered on 7/28/23. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhale PO Q4hr PRN for SOB related to COPD, ordered on 8/2/23. Record review of CR #1's medical record revealed a Skilled Nursing Evaluation performed on 8/4/23 by LVN B, that revealed the resident had no difficulty breathing, had clear lungs, had a cough with effective airway and retained secretions, and was on respiratory antibiotics. Record review of CR #1's August 2023 MAR revealed, on 8/4/23 he had clear lung sounds at 9:00am before and after nebulizer treatments, assessed by RN B. He also had clear lung sounds before and after nebulizer treatments at 9:00pm, assessed by RN A. On 8/5/23 at 9:00am CR #1 had wheezy lung sounds before and after nebulizer treatments, assessed by LVN A. Record review of CR #1's August 2023 MAR revealed on 8/5/23 he received the following medications: - Arformoterol Tartrate Inhalation 15mcg/2ml, 2ml inhaled via nebulizer at 9:00am given by LVN A. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhaled at 9:00am given by LVN A. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled at 6:25pm given by RN A. Record review of CR #1's medical record revealed on 8/5/23 Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act, 1 puff Q6hr PRN wheezing, AND Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled Q4hr PRN SOB, were not given by LVN A. Record review of CR #1's medical record revealed a progress note from RN A on 8/5/23 at 6:20pm that stated, Seen patient sitting at bedside having SOB, difficulty speaking, using accessory muscles [muscles other than the diaphragm that indicate labored breathing] and breathing through his mouth, heard crackles, gave PRN Ipratropium-Albuterol inhalation- not working - still having respi distress; checked vital signs BP 128/72 PR 112 Temp 98.2 and O2 sat at 97% with O2 at 4LPM via NC; reported to NP as patient said he was having this the whole day; [NP A] sent message to send patient out to hospital due to worsening respi distress; called 911, informed DON, and family since [family] is in the room. Called [name of the hospital] and gave report. Ambulance came and left with patient at left at 1910 [7:10pm]. Record review of CR #1's medical record revealed an administration note on 8/5/23 at 6:25pm by RN A that stated, she gave Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3ml. She also stated, patient complained of SOB, heard crackles, unable to speak properly, breathing to his mouth [breathing through his mouth], vital signs checked; 128/72; pulse 113; 97% O2 sat via 4LNC. Record review of CR #1's EMS Transport Report from 8/5/23 revealed they arrived at the facility at 6:57pm. According to the report, his primary symptom was respiratory distress. Per the report at 7:01pm, Pt was found to have an increased respiratory effort. Lung sounds were found to be diminished in the lower lobes bilaterally and rhonchi [continuous gurgling/bubbling sounds heard during inhalation and exhalation] in the apexes [very top] bilaterally. At 7:05pm EMS placed a non-rebreather mask on the resident and increased his oxygen to 10LPM and Pt respiratory effort improved once on the non-rebreather mask. According to the EMS narrative report taken by EMS #1 They found the patient sitting upright in his bed with a nebulizer mask on in the process of finishing a treatment. The patient was awake, alert, and appeared to have an increased effort for respirations. The patient's [family] reported she arrived to the facility about 4:00pm today. She stated she found him having difficulty breathing. She stated he could only get one word out at a time. The patient's [family] stated she had to make a scene to have the nursing staff come in to treat him. The [family] stated he was supposed to be getting nebulizer treatments throughout the day and they had not done one until she arrived. She stated he did not appear to be getting any better and the facility staff did not want to call for EMS . In an interview with family at the hospital on 8/6/23 at 3:44pm, she revealed staff were not listening to CR #1's lungs regularly on 8/5/23, to know if he needed his neb treatments. She said that CR #1 had bad COPD and was not getting his PRN neb treatments regularly throughout the day on 8/5/23. She said that CR #1 knew when his COPD was flaring up and when he needed his neb treatments, but staff were not giving them to him, so when she got to the facility on 8/5/23 at around 4:00pm he was gasping for air, pale, and making guggling sounds. LVN B, a nurse from another hall came in the room to assess him, and the family member asked her to have an MD come assess CR #1 or to send him to the hospital. The family member stated LVN B told them that he did not need to go to the hospital. CR #1 tried to explain how he was feeling and LVN B cut him off and said, Listen to me! The family member said she was very rude, demanding, and did not want to listen to anything they had to say. The family member also said that LVN B told them he was having problems from drinking/eating lying down. The family member said that was ridiculous and they were never sent to the hospital. The family member said finally RN A nurse came and listened to what they were saying and called the MD for an ER transfer order, and they were sent to the hospital. The family member stated RN A was the only one who listened to them. In an interview on 8/6/23 at 4:30pm with the Charge Nurse at the hospital, she said the admitting diagnosis for CR #1 was shortness of breath and he would be there for a few days, getting diuretics (water pills), neb treatments, steroids (helps with inflammation), and antibiotics. In an interview on 8/6/23 at 6:27pm with RN A she said she was the nurse who came on shift at 6pm on 8/5/23. She took report from LVN A and he said that CR #1 had been requesting to go to the hospital all day, so she saw him first at about 6:30pm. She said she took his vital signs, and they were ok, but he appeared to be physically having a hard time breathing. She stated he was using his accessory muscles to breathe, and he looked uncomfortable. She said she gave him some neb treatments, but they did not work, so she called the MD and told her that CR #1 had been breathing like that all day. The MD said to send CR #1 to the hospital. RN A was not sure why LVN A did not send CR #1 to the hospital. She said if the resident/family requests to go to the hospital, they do not tell them no, but staff would perform a nursing assessment first to see what was wrong and if the resident really needed to go to the hospital. She said, then they call the MD with the assessment findings, and it was up to the MD if they wanted to send the resident or not. RN A stated the family had mentioned to her that no one was helping them (CR #1 and family) the whole day until she arrived, and she was the first one to help them. Record review of CR #1's medical record on 8/5/23 revealed no documentation from LVN A that he contacted the MD or the NP. There was no documentation of an assessment of CR #1's lungs, or vitals taken around the time CR #1 complained of increased shortness of breath. In an interview on 8/6/23 at 3:12pm with EMS A he revealed when he arrived in CR #1's room it was evident he was struggling to breathe. He said CR #1 had increased respirations, belly breathing, and could only say a few words at a time without stopping to catch his breath. He stated the family member had told him she got there at about 4:00pm and had to really fight for CR #1 to get neb treatments. CR #1 was on his 2nd neb treatment when EMS arrived. In an interview on 8/17/23 at 10:23am LVN A stated CR #1 was congested when he assessed his lungs in the morning. He remembered that CNA A came and told him that CR #1 had eaten something, and it went in the wrong tube. He said CR #1 started complaining of increased SOB around 5:00pm and when he assessed his lungs he was still just as congested as he was in the morning, and his vitals were normal. He stated the family wanted him to go to the hospital, so he called the MD. He said the MD called back and said he was not taking care of the resident and for him to call his NP. He said he then called the NP and she said to send the resident to the hospital. LVN A said by the time the NP said to send the resident to the hospital, it was shift change already. He stated CR #1 did not appear to be working harder to breathe and looked the same. He said he did not remember if he gave the resident neb treatments but knew he was already on Levaquin (antibiotic) and had other meds ordered. LVN A also did not remember if he had documented his phone call, assessment, or vitals. He did not know why he did not document them, he said he must have forgotten. According to LVN A, he considered a change in condition was worsening vital signs, worsening condition from baseline, change in mental status, or unresponsiveness. In an interview on 8/17/23 at 2:10pm with NP A she stated she was notified about CR #1's condition by the nurse via text at 6:23pm and she replied via text to send him to the hospital at 6:27pm. She said she did not talk to anyone else regarding CR #1 prior to that date/time. A message was left for MD A on 8/17/23 at 11:09am, but he did not call back. In an interview with the DON on 8/17/23 at 3:06pm he revealed it was his expectation of staff to assess the resident, give PRN meds, and reach out to the MD when a resident came to the facility, newly discharged from the hospital with COPD exacerbation, and had shortness of breath.The DON said he oversaw the staff's trainings/competencies and assessed the nurses for competency. He said he provided yearly competencies as well as in-services/trainings, and the staff complete online trainings continuously. He stated that LVN A was PRN, new to the facility, and worked at a couple other places as well. The DON stated that a change in condition would be anything outside of the normal for the resident. He said if the resident had COPD, then it would be anything that was not normal for him, which would include increased shortness of breath. He also stated it was his expectation that if there was a change in condition that a progress note be filled out, an assessment of the resident, vitals, what treatment was given, and when the provider was spoken to and what they said should also be documented. The DON stated he expected the nurses to provide a focused assessment for the particular concern at hand. He said if the resident complained of being SOB, he expected a focused respiratory assessment, to give any medications available for that concern, and then call the MD if the resident did not improve. He stated the same would apply if the resident complained but everything was normal with the resident. The DON stated the nurse should contact the MD immediately if the meds did not help. He also stated the 5:00pm nurse should have evaluated, provided treatment, and called the MD before change of shift, and this incident would not be something to hand off to the next shift. Record Review of LVN A's Training Transcript dated 8/17/2023 revealed no documented training for significant change of condition. Record review of the facility's Policy and Procedure on Acute Condition Changes- Clinical Protocol (Revised March 2018) read in part: .2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs .d. Level of consciousness .g. Onset, duration, severity .3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident .and how to communicate these changes to the Nurse .5. The physician and nursing staff will review the details of any recent hospitalizations and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having addition complications .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician .8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or practitioner) will respond in a timely manner to notification of problems or changes in condition and status .10. The nurse and physician will discuss and evaluate the situation .1. The physician will help identify and authorize appropriate treatments .3. If it is decided .the physician will authorize transfer to an acute hospital, Emergency Room, or another appropriate setting .1. The staff will monitor and document the resident's progress and responses to treatment . Record review of the facility's Policy and Procedure for Chronic Obstructive Pulmonary Disease (COPD)- Clinical Protocol (Revised November 2018) read in part: .2. In addition, the nurse shall assess and document/report the following: a. Vital signs (including detailed descriptions of respirations) b. Full lung assessment (including sounds of wheezing, sputum production) .d. Pulse oximetry result e. Onset, duration, frequency, severity . 3. The physician and staff will identify individuals with risk factors for developing COPD or for exacerbation of existing COPD .7. The physician will identify individuals with complications of COPD; for example, cor pulmonale [alteration in structure/function of the right ventricle of the heart caused by respiratory system, causing pulmonary hypertension], arrhythmia [irregular heart rhythm] or lethargy [very tired and hard to wake up], or confusion due to hypoxia .3. The physician and staff will identify relevant elements of the care plan; for example, what symptoms to expect (dyspnea, cough, fever, progressive activity intolerance, etc.), how often and what to monitor, when to report findings to the physician .4. Key objectives of COPD management include: a. Minimize disease progression b. Relieve symptoms .e. Prevent and treat exacerbations .11. The physician and staff will identify and manage complications of COPD, such as acute infections, hypoxia .and respiratory failure .12. The staff and physician will identify and treat acute exacerbations of COPD; for example, recognizing and reporting when an individual with COPD has a change in function or activity tolerance, increased dyspnea [trouble breathing], additional sputum production, cough, increasing lethargy or confusion, increased wheezing, increased respiratory or heart rates .1. The staff and physician will monitor the progress of individuals with COPD, including ongoing evaluation and documentation of signs and symptoms and condition changes . Record review of the facility's Policy and Procedure for Change in a Resident's Condition or Status (Revised February 2021) read in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician of physician on call when there has been a(n): .d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly .i. Specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status 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 details observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . On 9/15/2023 9:10 a.m. an Immediate Jeopardy (IJ) was identified. The Administrator was notified and provided the IJ template on 9/15/2023 9:10 a.m.; and a POR was requested at that time. After several revisions, the POR submitted by the Administrator was accepted on 9/19/2023 at 3:30 pm. PLAN OF REMOVAL The DON, ADON in-serviced all licensed staff, via live in-service, on observing for changes of condition on September 15th, continuing through September 18, 2023. The training included when to notify MD of a change of condition. All nurses should inform the MD after the following steps have been taken. 1. A nursing assessment has been completed. 2. PRN medications are administered as ordered. 3. A reassessment is completed and determined that interventions were not effective. 4. Call MD with information obtained and carry out any new orders provided. In the instance a patient or family member was requesting to go to the hospital the following steps should be taken: 1. Reassure patient and family 2. Follow nursing process and complete a nursing assessment 3. Provide PRN medications as ordered 4. Reassess patient and determine if interventions are effective 5. Call MD with information and carry out any new orders provided In the instance when the MD does not answer in a prompt manner, (within 2 calls), the nurse should call the Medical Director for further instructions. If the patient was unstable the nurse should call 911 immediately. This would include abnormal vital signs outside of the patients previously assessed normal, for example a sustained oxygen saturation of 85% or lower with no success increasing after oxygen therapy. On 9/15/2023, a chart audit for recent significant changes of condition was completed by management nurses. All changes were reported to the MD's. Current patients with the above conditions were assessed by licensed nurses. Assessments included blood pressure, pulse, respirations at rest, respirations with activity, temperature, lung sounds and oxygen saturations. In addition, return demonstrations were observed by the assigned nurse managers to ensure competency. There were no incidents when prn respiratory treatments were required, based on nursing assessment. Those assessments were placed in the appropriate medical chart upon completion. All non-PRN licensed nurses were trained by September 19th, 2023. Staff will have had training before their next scheduled shift or will not be allowed to work the floor until said training is completed. MONITORING During IJ implementation dates 9/15/2023-9/19/2023, investigation, interview and monitoring for Notify of Changes, this surveyor observed nursing staff doing their work, interviewed nurses on day and night shift, interviewed other staff members regarding and new and recent trainings by, computer, licensed in person in-service. 12 of 12 nursing staff were able to verbalize and verify new and reinforced training regarding changes of condition, SBAR documentation, Oxygen therapy, respiratory medication, following orders, PRN medications and documentation of refusal of medications. Record review of Training between 9/15/2023-9/19/2023 included: call the doctor or the nurse practitioner, and if the doctor or nurse practitioner do not respond timely or appropriately when the patients change of condition is reported- they should report to DON/ADON and the Medical Director if ADON/DON not available. The training consisted of specifically observing acute changes in patients with COPD, respiratory infections and other diseases of the lungs. Patients were assessed with COPD, respiratory infections by licensed nurses. Assessments included blood pressure, pulse, respiration at rest, respiration with activity, temperature, lung sounds and, oxygen saturation. Nurses report in the event family member or resident request to be sent to hospital, they will inquire as to why, perform assessment, SBAR, contact medical doctor or nurse practitioner, explain to the doctor/nurse practitioner what the resident is requesting, the vital signs, signs and symptoms they observed, receive orders, follow orders, in the event no new orders are given, DON will be contacted and medical director may be contacted. Interviews between 9/15/2023-9/19/2023, 12 of 12 Nurses were able to verbalize: signs and symptoms of COPD, signs and symptoms of COPD, ineffective breathing pattern assessment, ineffective breathing pattern interventions, activity intolerance assessment, activity intolerance interventions, deficient knowledge assessment, deficient knowledge interventions, respiratory assessment, oxygen administration, nebulizer therapy, small volume, and proper documentation. Record Reviews between 9/15/2023-9/19/2023, were performed regarding the training and monitoring to be done by management when and found to be compliant with standards of care. Residents were interviewed between 9/15/2023-9/19/2023 and were pleased with the care received by all staff members in the facility and reported they got their medications timely and when they asked for prn medications, the prn medications were given timely. The Administrator, DON were informed the Immediate Jeopardy (IJ) was removed on 09/19/2023 at 1:09 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.