**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify the resident representative(s) when there was an accident that caused a need to alter treatment significantly for 1 (Resident #1) of 2 residents reviewed for notification of changes. The facility nurses failed to immediately consult and notify the Physician when resident #1 sustained a fall with head injury on [DATE] at approximately 6:19 am and had subsequent altered mental status that required additional treatment in the form of neurological checks; the resident was pronounced deceased [DATE] at 11:59 am . The facility nurses further failed to notify Resident #1's emergency contact, RP #1, that Resident #1 suffered a fall and hit his head, per self-report, on [DATE] at approximately 6:19 am with documented lethargy; RP #1 was notified at 10:48 am that Resident #1 was being transported to the hospital by EMS. The resident was pronounced deceased [DATE] at 11:59 am. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 4:00 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 evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving interventions, treatments, and care by recognizing and addressing the physical, mental, and neurological dysfunctions such as altered state of consciousness, nausea, vomiting, cognitive decline, confusion, memory loss, and changes in behavior in an effective and timely manner to prevent residents from further harm, injury, or death. Findings included: Record review of Resident #1's undated face sheet, printed on [DATE], revealed that he was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses that included type II diabetes, heart failure, and COPD (lung disease that makes it difficult to get oxygen to the body), and acquired absence of the left leg below the knee (amputation that was diagnosed [DATE]). It further revealed that his emergency contact was RP #1; FAM was listed on the face sheet but not with any designation (i.e. RP, emergency contact etc) Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS of 8, which indicated moderate cognitive impairment, he was marked as requiring one person to assist with bed mobility, 2+ persons to assist with transfers and toilet use. It further revealed that Resident #1 required a wheelchair for mobility. It further revealed that he was always incontinent of bowel and frequently incontinent of bladder. The question that asked the primary medical condition category that was the cause of admission did not mark amputation, but entered other orthopedic condition, then gave the billing code encounter for orthopedic aftercare following surgical amputation. Further review revealed that Resident #1 was marked as not having any falls since admission/entry or reentry or the prior assessment. The question about if Resident #1 had a fall any time in the last month prior to admission/entry or reentry was left blank, as was the question for 2-6 months. Record review of Resident #1's active orders revealed he was on two blood thinners, aspirin and Plavix . Resident #1 had an order that started [DATE] for 81 mg aspirin once daily and an order for Plavix (clopidogrel bisulfate) 75 mg once daily that started [DATE]. Record review of Resident #1's undated care plan revealed that Resident #1 was visually impaired due to glaucoma with an intervention encouraging use of glasses. It further revealed that Resident #1 was at risk of falls and was initiated [DATE] with interventions of call light use, anticipate resident needs, ensure proper footwear and keep furniture locked. Another concern addressed in the Care Plan was blood thinner use with the intervention of increased monitor/document/report to MD signs of anticoagulant (blood thinner) complications to include lethargy, change in appetite, and change in mental status which was initiated on [DATE]. Record review of the facility incident report dated [DATE] at 6:19 am revealed that LVN A entered that Resident #1 slid out of wheelchair next to bed, and he was unable to give a description of the incident. It further revealed the resident was assessed, had no injuries and was assisted to bed. The resident was not taken to the hospital at this time. Resident #1's level of consciousness was documented as lethargic (drowsy). Record review of Resident #1's follow-up question report printed [DATE] revealed that Resident #1 refused his breakfast on [DATE] at 9:25 am and that he refused a supplement or substitute as well. In an interview with FAM on [DATE] at 11:00 am he stated that his father had been eating everything in sight for the last few months. He said it was unusual for Resident #1 to refuse any meals, especially recently. In an interview with CNA E on [DATE] at 2:57 pm he stated he worked the overnight shift on the night of [DATE] - [DATE] and got Resident #1 out of bed before he finished his shift at 6:00 am, probably between 5:30 am and 5:45 am. He said that Resident #1 was able to assist CNA E with getting out of bed, dressed and into his wheelchair. He stated Resident #1 was his normal self at this time. In an interview with CNA C on [DATE] at 7:51 p.m., she stated on [DATE] she started checking the 100 hall (where Resident #1 resided) around 5:50 a.m. and she went to do some charting. She was the first care giver to find Resident #1 and he was not responding to questions, so she called for help and LVN A and LVN B arrived, and HK was already on the hall and joined in the room. She said as the nurses evaluated Resident#1, he became more responsive and he was assisted to bed using the mechanical lift. He was put in bed before 6:30 a.m. (using the lift after his fall). In an interview with LVN A on [DATE] at 8:24 p.m., she stated on [DATE] around 6:30 a.m. she checked Resident #1's blood sugar and it was normal. Resident #1 was putting his prosthetic leg on, so she went to Resident #2 and checked his blood sugar, she went to the med cart in the doorway to get insulin sliding scale to administer and while her back was turned she heard Resident #1 fall. He had no signs of injury or impaired thinking., She got LVN B and CNA C to assist with mechanical lift use to get Resident #1 back in bed. She said she was the first to find him. LVN B checked Resident #1's vitals while LVN A messaged NP that Resident #1 had fall with no injuries around 6:30 am. She stated she notified DON and ADM. She stated she called FAM and asked that FAM give LVN A 15 minutes before FAM notified RP #1 because she would call and ask questions. LVN A said she needed 15 minutes to finish charting, complete the fall report, check vitals, and start neuro checks before RP #1 was informed. In an interview with LVN D on [DATE] at 8:48 p.m., he stated that on [DATE] he came on shift at 7:00 a.m. and was informed of Resident #1's q 15 minute neuro checks and he was performing the checks and entering them in the medical record. He stated he set a phone alarm to ensure this was done timely until sometime between 10:00 a.m. and 11:00 a.m. when the resident was not responsive when he attempted to get vitals,. LVN D said Resident #1 was tensed up and may have choked (aspirated). He called for assistance then dialed 911 for EMS. Record review of Resident #1's [DATE] neuro checks revealed that all 7 neuro checks documented by LVN D that started at 7:05 a.m. and ended at 9:20 a.m., were all entered into the medical record after 3:00 p.m. (3 hours after Resident #1 was pronounced deceased ). The 9:55 a.m. neuro check was entered at 9:56 a.m. and had a systolic bp of 130 and no diastolic bp recorded; the 10:10 a.m. neuro check was entered at 10:13 am and his blood pressure was 105/59; and his 10:25 a.m. neuro check was entered at 11:49 a.m., had a bp of 90/54 and Resident #1 was not responding to verbal stimuli (noise). During an interview with HK 1 on [DATE] at 11:53 a.m., she stated she was on the same hall as Resident #1 and had passed his room sometime after 5:00 am on [DATE]. She said she went to the linen closet, and Resident #1 was in his wheelchair. She heard a commotion and went to Resident #1's room and he was not responding to staff, and he was rigid as he was being lifted from the floor to the bed with a mechanical lift. She stated Resident #2 was watching the whole time. She stated that as CNA C, LVN A and LVN B were turning Resident #1 using the mechanical lift to get his head to the head of the bed that she heard gurgling from Resident #1. She stated when Resident #1 was in the bed she heard a gurgling/snore noise from Resident #1 and placed a basin within reach for him to vomit in; she said Resident #2 then stated that Resident #1 had a seizure 2 weeks ago. She (HK 1) was upset because this was not normal for Resident #1 and she was concerned. Record review of Resident #1's assessment titled Event Nurses Note 8 hr fall with an effective date of [DATE] at 6:32 a.m. revealed LVN A documented that Resident #1 was unable to give a statement about the fall, FAM was notified at 6:30 a.m., not RP #1, he does not walk and required 1 staff to assist with toileting, transferring, and bed mobility. It further noted he had no problem with cognition but was put on monitoring (neuro checks). Record review of Resident #1's Incident audit report dated [DATE] at 6:19 a.m. documented by LVN A revealed in the section labeled: injuries observed at the time of the incident, indicated Resident #1's level of consciousness was lethargic (drowsy) and this was documented on [DATE] at 6:29 a.m Record review of Resident #1's Fall Risk Assessment effective [DATE] at 6:47 a.m., revealed LVN A documented that Resident #1 had adequate vision, was able to stand, had balance problems when standing, had balance problems when walking, Record review of Resident #1's progress notes with an effective date of [DATE] at 10:00 am written by the DON on [DATE] at 4:19 p.m. it indicated Resident #2 (roommate) stated Resident #1 transferred from the bed to the wheelchair then was putting on his prosthetic leg and fell. Nurse assessed and found no injuries. Anti-tippers (device to prevent wheelchair from tipping) were to be placed on the wheelchair. No progress notes were found documenting the fall nor the consultation with Resident #1's physician; this was the first progress note dated [DATE]. Record review of the ambulance patient care report revealed that 911 was contacted on [DATE] at 10:44 am and the ambulance arrived at the facility at 10:48 am. Further review revealed 911 was contacted for a cardiac event related to a fall with head injury around 6:00 am. During an interview with EMS on [DATE] at 8:00 am he stated that 911 was notified [DATE] at 10:44 am to respond to the facility for a resident who had a fall that morning and hit his head. They arrived at 10:48 am and staff handed them papers but did not inform them of the OOH-DNR among the papers, so when Resident #1 was in the ambulance in the parking lot and his heart stopped they initiated CPR, and it was continued at the ER until the paperwork was found and CPR was stopped. Resident #1 was pronounced deceased on [DATE] at 11:59 am. In an interview with FAM on [DATE] at 11:00 am he stated he was called on [DATE] between 6:20 am and 6:30 am about Resident #1, which had never happened because he travels extensively for work. Staff stated Resident #1 had a fall and please wait for a while to notify RP #1 so staff had time to finish documenting. FAM stated due to his work situation he did not call RP #1 because he forgot. He received a call from RP #1 that DON called RP #1 on [DATE] at 10:46 am to inform her that Resident #1 was being taken to the hospital. In an interview and record review with RP #1 on [DATE] at 11:30 am she stated the facility usually called her about Resident #1 so she could go to medical appointments and such, but she was not called on [DATE] until after 10:30 am when Resident #1 was being sent to the hospital Record review of her phone log revealed no missed calls on [DATE] prior to 10:30 am. She stated she asked the ADM why she was not notified and the ADM stated that Resident #1 was his own responsible party and the facility cannot call every time a medication or order was changed or every time someone had a fall unless they went through a legal process. She stated had she been notified she would have been at the facility to check on Resident #1 earlier. Record review of the eTransfer form with effective date [DATE] at 11:02 am revealed Resident #1 was transferred to hospital because he had a fall that morning and was displaying a change in mental status; his gaze was fixed with pupils non-restrictive, unable to verbalize anything, hypotensive at 90/54, pulse 79, bs 119, possible aspiration (choking) with vomiting. Transfer time was 11:02 am and it was an emergency transfer, meaning it was done prior to notification of NP or MD. Resident level on consciousness was stuporous (slow to react), he was not oriented to person, place, time or situation, he had unclear or no speech, was incontinent of bowel and bladder. Record review of the eTransfer audit report revealed the following vitals were the most recent on [DATE] at 11:02 am: BP [DATE] 1:09 am 134/66 Pulse [DATE] 1:09 am 74 Respiration [DATE] 8:02 am 16 Blood sugar [DATE] 6:01 am 118 Updated on [DATE] at 11:09 am by LVN D: BP [DATE] 11:06 am 90/54 Pulse [DATE] 11:06 am 79 Respirations [DATE] 11:06 am 20 Blood sugar [DATE] 11:06 am 119 Record review of the SBAR effective [DATE] at 11:24 am for Resident #1 revealed at [DATE] at 11:06 am Resident #1's bp was 90/54, his pulse was 79, and his respiration was 20 at the same time and his glucose was 119. Resident #1 had a decrease in level of consciousness and seizure, his pupils were non-restrictive, he was non-verbal, and he was vomiting. He was being transferred to the hospital and NP was notified at 11:00 am per the SBAR. Record review of the SBAR audit report (a report in EHR that shows date and time report was created, auto-captured date and time) revealed the SBAR was created by LVN D on [DATE] at 1:30 pm. In an interview with NP on [DATE] at 10:00 am she stated if a resident on blood thinners had an unwitnessed fall with altered thoughts that the resident should be sent to the hospital (blood thinners increase the risk of internal injury) . In an interview with the ADM on [DATE] at 7:27 pm via telephone she stated that she saw Resident #1 shortly after arriving to work on [DATE], which would be after 8:00 am. She stated that Resident #2 told her how Resident #1 fell, that he had self-transferred from the bed to the wheelchair and was pulling on his prosthetic leg and the wheelchair went one way and Resident #1 went another. The ADM originally denied telling RP #1 and FAM that the facility cannot notify someone every time a resident has a fall or needs a medication change, but then corrected herself upon learning of a recording of the conversation. She said she expected if a resident had a fall and potential head injury that the physician should be contacted, neuro checks started and the resident should be sent to the hospital after the physician was contacted. In an interview with the DON on [DATE] at 8:40 pm she stated the potential harm of the nurse using clinical judgement and possibly missing a serious injury could lead to worsening symptoms and death of the resident. She stated NP was easier to reach and that was why staff contacted the NP and not the physician. In an interview on [DATE] at 10:18 am with NP via telephone she stated, when asked about when she was notified of Resident #1's fall, it was absolutely not by text message and it was definitely by phone call; she stated her cell phone call log did not go back that far ([DATE]) but that she got a call in the morning and knew the resident was on blood thinners and even if she was told he had altered mental status because it was this resident she would not have recommended sending him to the hospital for evaluation (repeated several times Resident #1 was not compliant with diet or fluid restrictions); she stated even if he had been unconscious and regained consciousness she would not send this resident to the hospital. She stated she was uncertain if Resident #1's physician was informed of the fall because she does not work for him; she stated she speaks to him on average once per month. She stated she did not order neuro checks after the fall, but it was done per facility protocol. She confirmed when prompted that she spoke to a nurse at the time of the fall but was informed via text message later that morning that Resident #1 was sent to the hospital. In an email interview with ADM on [DATE] at 10:07 am, she responded to request for screenshot of notification from LVN A to NP by stating that it was documented in Resident #1's record; after being asked if she was refusing to provide the requested documentation she replied on [DATE] at 10:56 am with the requested screenshot. Record review of a screenshot photo revealed a text message from LVN A to NP on [DATE] at 6:31 am revealed notification via text from LVN A resident 1 slid out of wheelchair this am no injuries noted at this time and the response from NP thx (thanks). After the following attempts to reach the physician, leaving messages for a return call, Medical Director, who was Resident #1's physician has not returned any calls: [DATE] 3:00 pm [DATE] 10:15 am [DATE] 9:45 am Record review of facility self-report in TULIP, incident 445046 dated [DATE] stated Resident #1 fell in room after transferring himself into wheelchair and attempting to put prosthetic leg on and hit head. Resident was assessed and put on neuro check precautions. Physician and resident representative were notified at time of fall. Intervention at time of fall put in place was antitippers to resident wheelchair to prevent resident from flipping over. Several requests were made from ADM and DON for documentation on [DATE] by LVN A of notification to physician and physician response to notification related to Resident #1's fall around 6:19 am, but facility failed to provide documentation. ADM stated in an email that the notification was documented in the resident's record; record review revealed no progress notes that documented notification of the fall to the physician. Further record review revealed an assessment titled Event Nurses-Note 8 hr Fall - V2, entered by LVN A, which stated that Resident #1 was unable to give a statement . under name of physician notified it showed the name of NP and for date and time of physician notification it stated [DATE] 6:30 am. No documentation was found in the EHR to indicate the physician was notified and nor did the facility provide that requested documentation. Record review of the facility policy for notifying the Physician of Change in Status, revised [DATE], revealed the nurse should not hesitate to contact the physician at any time when an assessment [NAME] their professional judgement deem it necessary for immediate medical attention. This facility utilizes the INERACT INTERACT tool, Change in Condition-When to Notify the MD/NP/PA to review resident condition and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. 3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident as has specified otherwise. 6. The nurse will monitor and reassess the resident's status and response to intervention. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and respond to interventions. 8. If the resident remains in the facility and a significant change has occurred, update the care plan accordingly. 9. Faxes should be following up by the end of the business day. 10. If a resident is transferred to the hospital, complete a transfer form. Send a copy of the most recent history and physical, progress note, advance directives, MAR, diagnosis list, and pertinent lab and x-ray reports to the hospital. Document actions in the resident's clinical records. 11. Abnormal lab, x-ray and other diagnostic reports require physician notification. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 12:26 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on [DATE] at 12:46 PM. The following plan of Removal submitted by the facility was accepted on [DATE] at 10:51 am: PLAN OF REMOVAL [DATE] Plan of Removal Problem: F580 F580 -The facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a need to alter treatment. Interventions: o As of [DATE] Resident #1 no longer resides in the facility (died [DATE]) o Regional nurses, DON, and ADON will review any resident with change of condition in the last 7 days for proper notification to MD on [DATE]. o DON/ADON/Regional Nurse in-serviced LVN A individually r 1:1 regarding proper notification of Physician on [DATE]. In-services: All staff not in-serviced on [DATE] including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o All charge nurses were in-serviced on [DATE] by the Compliance Nurse/DON/ADON regarding proper notification of physician. Do not text a physician for resident change notification, the physician must be notified by phone and the notifying nurse must receive a responsive directive from the physician, i.e., receipt of new treatments or medication orders, transfer to the hospital, no new orders, etc. The Administrator, Compliance Nurse, DON, and ADON were in-serviced by the VP of Clinical Services on [DATE]. o All charge nurses were in-serviced on [DATE] by the Compliance Nurse/DON/ADON to enter completed assessments into EHR by the end of shift for the change of condition. The Administrator, Compliance Nurse, DON, and ADON were in-serviced by the VP of Clinical Services on [DATE]. o All charge nurses were in-serviced on [DATE] by the Compliance Nurse/DON/ADON that if a resident has a significant decline, i.e., the resident is no longer responding to stimuli, pupils are not reactive to light and/or are fixed, etc., it is considered an emergency and EMS must be notified by 911. Notify the physician of the transfer prior to end of the shift after the resident has left the facility. The Administrator, Compliance Nurse, DON, and ADON were in-serviced by the VP of Clinical Services on [DATE]. Medical Director was notified by the DON on [DATE] at 2:03 pm about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on [DATE] by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the EHR Dashboard for clinical alerts for any resident change of condition with documentation of physician notification, starting [DATE]. This will be done 7 days per week and will continue x 6 weeks. o DON/ADON will monitor completed assessments entered in EHR to ensure they were entered into EHR prior to end of shift. Monitoring will take place 7 days per week and will continue x 6 weeks. MONITORING THE POR : Record review on [DATE] 11:20 AM of the Plan of Removal (POR) binder revealed: the ADM, DON, ADON, and Regional Compliance Nurse were all in-serviced by VP of Clinical Services on [DATE] on the below in-services: Proper Notification of Physician with directives to not text a physician for resident change notification, the physician must be notified by phone and the notifying nurse must receive a responsive directive from the physician, i.e., receipt of new treatments or medication orders, transfer to the hospital, no new orders, etc. If a Resident has a Significant Decline with directives if a resident has a significant decline, i.e., the resident is no longer responding to stimuli, pupils are not reactive to light and/or are fixed, etc., it is considered an emergency and EMS must be notified by 911. Notify the physician of the transfer prior to end of the shift after the resident has left the facility. Completed Assessments with a directive to enter completed assessments into EHR by the end of shift for the Change of Condition. Charge nurses were then in-serviced on the same information on [DATE] by the DON and the ADON with assistance by the Regional Compliance Nurse. In an interview on [DATE] at 11:45 am with LVN F and she said she has worked at the facility for 14 years. She was in-serviced on Contacting Doctors, Neuro Checks, Fall Assessments, and Timely Assessments in general. She provided the below information: Anytime there is a change in condition on your resident, you must call the doctor. They are no longer allowed to text the doctor for a change-in-condition. Neuros must be completed timely when they are due and documented into EHR. Assessments must also be completed timely and entered into the system when they are due. In an interview on [DATE] at 12:05 pm with LVN D he said he has worked at the facility for 3 years. He provided the below information: He is PRN but came to the facility today to complete the in-services. He was in-serviced on Proper notification on change of conditions, including do not text the doctor. You must call for all emergencies. It cannot be a texted and you must provide the doctor with a Situation, Background, Assessment and Recommendations (SBAR). Neuro Evaluations and Proper documentation in EHR: timely documentations, when you complete a Fall Assessment or Neuro check, you must enter it in the system at that time, or no later than the end of your shift. In an interview on [DATE] at 12:20 pm with LVN G she said she has worked at the facility for 1.5 years. She provided the below information: Notifying the Doctor Contacting doctors in a timely fashion depending on the situation . She was provided a copy of the documentation and it was also placed in their 24-hour nurse's report. If it is an immediate situation, you must call and not text. When they have an incident that requires contacting the doctor, they must complete an SBAR and depending on the situation, the SBAR will tell them if it is immediate, or if they can wait. Neuro Checks They need to be done in a specific format and timed intervals. A copy of the scheduled Neuro Checks was placed in the 24-hour report book. It is very important to do it promptly even if EHR does not prompt you to do it, they know the schedule and should be completing them throughout their shift. They also have to notify the doctor for any change in condition. Fall Assessments If it is an unwitnessed fall, or they see them hit their head, they have to initiate Neuro Checks as well. The Neuro Checks need to be completed and the doctor need to be called and not texted. You also must notify the responsible party. The resident has to be followed-up for 3 days and documented in EHR. They also have to notify the doctor for any change in condition. When she was educated about the SBAR, it was explained when you complete it, it will inform you if it is an emergency or not. She did not know the SBAR determined for you because she would always call the doctor regardless. In an interview on [DATE] at 01:40 pm with LVN A and she said she has worked at the facility for less than one year. She provided the below information: She was in-serviced on Who to Call (if the Responsible Person does not answer, chart it, and then call the next person). If there is a Change in Condition, call the MD or the on-call doctor and not the NP, Neuro Checks are to be done timely even if you are administering medications, all documentation need to be entered at that time, or no later than the end of her shift. It was re-education as she had already been doing these things. What she knows now is not to call the Nurse Practitioner. She thought the NP was going to call the doctor. She also learned to make sure you always chart and document everything regardless of how minimal. As far as her job, she was already completing these tasks so her biggest take away is to call the MD and not the NP and to always call regarding any Change of Conditions and do not send a text. Also, to make sure all documentation is entered as soon as possible and no later than the end of her shift. In an interview on [DATE] at 02:00 pm with ADON andshe said she has worked here for 9 years. She was in-serviced on anytime there is a change in condition for the resident to notify the doctor immediately via phone call. They have an InterAct Tool that they can look at to see if they need to contact the doctor immediately or send the resident out[TRUNCATED]