**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure when there is a transfer or discharge of resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge appropriate information is communicated to the receiving health care institution; and the facility failed to provide and document sufficient preparation and orientation in a form and manner the resident could understand for one (Resident #1) of five residents reviewed for hospital transfers. 1. The facility sent Resident #1, who they indicated was having a behavioral emergency (pulling on his g-tube, ostomy and catheter) and was in danger of dislodging them, in a private non-medical transport vehicle and left him without facility staff or a family member to supervise him while in the ER waiting area.2. The facility failed to notify and coordinate with Resident #1's RP prior to sending him out to the ER, which did not allow the RP to select the preferred hospital of her choice or be there in time to supervise him and interpret for hospital staff. 3. The facility failed to provide the hospital ER with any clinical information prior to Resident #1's arrival on [DATE], including what his medical emergency was. 4. The facility did not notify and update the MD/NP that EMS refused to transport Resident #1 to the ER because they felt he was not having a medical emergency after the NP gave a verbal order to send him out. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included:Record review of Resident #1's face sheet, dated [DATE], reflected he was a 71yearold male admitted on [DATE]. Active diagnoses included nontraumatic intracerebral hemorrhage (bleeding within the brainstem), anxiety disorder (mental health condition causing agitation), colostomy status (surgical opening in the colon for stool elimination), urinary retention with catheter use (inability to empty bladder requiring a tube), and gastrostomy status (feeding tube placed into the stomach). Resident #1 had a family member [RP] listed as his representative.Record review of Resident #1's admission care plan, dated [DATE], reflected focus areas included risk for line dislodgement, infection, aspiration, weight loss, and dehydration. The care plan did not address any behavioral concerns. Record review of Resident #1's facility admission orders reflected he was not discharged from the hospital with any routine or PRN psychotropic medications, including anxiety medication. Additionally there were no transfer orders to send Resident #1 to the ER on [DATE]. Record review of Resident #1's admission nursing note written by RN F on [DATE] at 11:11PM reflected the resident was confused and anxious, attempted to pull at his tubes, and required onetoone supervision to prevent device removal.Record review of a follow up skilled nursing note on [DATE] at 3:57 AM reflected Resident #1's vitals were all within normal limits and he was in no pain. The skilled nursing note stated, .The resident is disoriented.The resident is unable to speak.Other Observations: Resident new admit day 1/3 alert and confused very agitated, anxious pulling tubes abdominal binder in place to secure g-tube, foley and colostomy. Awake all night resident on one and one. Total care with adl.Record review of Resident #1's nursing progress note, dated [DATE] at 12:31 PM by the DON, reflected, This writer received call from primary nurse that resident was attempting to remove urinary catheter peg tube and ostomy device. We were unable to successfully redirect the resident and he required ongoing higher-level care. Primary nurse was instructed by MD to send resident to ER for evaluation due to unable to keep resident safe in current building due to pulling lines and aggressive behavior. The DON further wrote, Action: 911 was called by primary nurse, upon their arrival this writer spoke with [name redacted] from [Fire Station] who advised this writer that paramedics would not be taking this resident to the hospital as per them he appeared to be medically stable and that the safety aspect of his care would need to be addressed with the [city Police Department or private transportation. This writer then requested nursing staff to arrange private transport via [private transport company] car. Related to RP notification, the DON wrote, Response: [RP] was notified of transfer and requested that resident be sent ‘anywhere but [previous hospital]' Resident was transported via [private transport company] to [different nearby hospital]. Information was relayed by this nurse to triage nurse at [nearby hospital], as well as to [ER MD] for continuity of care.An interview with Resident #1's RP on [DATE] at 11:45 AM revealed the entire discharge from the hospital, admission to the facility and discharge the next morning to the ER was a really bad experience. She stated Resident #1 was transferred to the ER without clinical documentation and without a staff escort. The RP reported that upon arrival, the resident's ostomy was leaking and he was agitated. The RP further stated the ER staff were upset because the resident was by himself, the ER did not receive information about the resident's diagnoses or reason for transfer and were unable to communicate with the resident who did not speak English. The ER staff asked the RP who transported Resident #1 to the ER and the RP assumed he was sent out 911. The ER nurses indicated to the RP that Resident #1 appeared to be brought in a wheelchair in a normal vehicle, no paperwork, no reports, no nothing. They told her Resident #1 was then transferred to a hospital wheelchair by the person who drove him there, taken to the front desk, and told the resident was there. The RP stated she found out Resident #1 was transported through a private company which was upsetting to her. The RP stated, They know this is not right, what they did with [Resident #1]! What if they had taken him and put him in the street? Who was this person transporting him? A medical person? No one stayed with [Resident #1] when they took him to the ER! The ER nurses told the RP that he was brought in through what looked like a ride share company. The RP stated, That is not a proper way to bring someone.I was like who are these people? They just dumped him? How would we know where he was? The facility was not responding, the (ER) staff heard me trying to talk to the facility about sending any reports. An interview with the DON on [DATE] at 10:45 AM revealed the facility initially attempted to send Resident #1 via EMS, but EMS declined transport, determining the situation was not a medical emergency. The DON stated staff then arranged private nonmedical transport. The DON confirmed only a medication list was sent with Resident #1 and verbal report was given to a different hospital prior to rerouting the transport. The DON acknowledged that no staff accompanied the resident and that the ER nurse contacted her and was upset and expressed concern that Resident #1 arrived unsupervised, nonEnglish speaking, and without medical documentation. The DON stated she also spoke with the ER physician who was also asking questions about why the resident was sent to the ER and why there was no information on him. The DON stated that when Resident #1 was brought into the ER, he was left in the ER by med transport as that is protocol. The DON stated that if Resident #1 had been brought in via 911, then he would have been taken back immediately to an ER bed and evaluated.An interview with LVN A on [DATE] at 1:04 PM revealed she was the 6a-2p nurse and arrived to work the morning of [DATE] around 5:45 AM and was told by the overnight nurse during report the staff was having problems with Resident #1, he did not sleep at all and was pulling at everything coming out of him, his foley, colostomy and g-tube. LVN A stated the overnight nurse was not the normal nurse who worked, it was a PRN nurse. When LVN A went to see Resident #1 during her first rounds, he had disconnected his g-tube tubing. LVN A stated Resident #1 did not speak English and the facility did not have a interpreting services. LVN A stated and he was not letting her reconnect his g-tube and he did not know what was going on cognitively. LVN A stated the facility did have a supply of abdominal binders available to use for residents in that situation and she could have placed one on him quickly to prevent him from accessing the gtube but did not. LVN A also stated Resident #1 had no routine or PRN meds to administer to help him relax. LVN A stated the facility did have PRN anxiety medications available for behavioral emergencies in an e-Kit [facility's emergency medication supply], but she did not contact the MD or NP to ask about those as a possible intervention. LVN A stated, I called the staffing person and said there was someone watching him over night but I can't stay with him, I didn't know he was an issue til I got here, so DON called me and said he was danger to himself, so send him out.and to send him back where he came from. LVN A stated when the EMTs arrived, they took Resident #1's vitals and even though he was still pulling at everything, they said it was not a medical emergency and would not take him. When LVN A spoke with the DON again, she told LVN A to have their transport services take Resident #1 back to the hospital. LVN A stated there was a driver the facility used who did medical appointments and hospital transfers, but she was out in the field busy, so non-medical transport was set up instead. LVN A stated she did notify Resident #1's RP after he was picked up by the private transport company of his transfer to the ER. She said the RP told her Resident #1 could not go back to the hospital he had just come from the day before, But he was already in route. LVN A then contacted the DON who called the private transport person enroute to tell him to take the resident to the closer ER by the facility. LVN A stated she contacted the RP back to let them know, but the RP was not happy with the local ER because it was too far for her to get too. LVN A stated, [The RP] never told me where [they] wanted him to go. I was already frustrated and two hours behind schedule and called [the RP] twice and then I sent [the RP] to the DON and I don't know anything after that. LVN A stated that the facility could send residents anywhere the family wanted and did respect family requests. LVN A stated she did not call the facility's MD or NP G but did let NP G know after the transfer to the ER was done. She said NP G was housed onsite at the facility every weekday but was not at the facility when the decision was made to send Resident #1 to the ER. Regarding clinicals and transfer documentation, LVN A stated Resident #1 did not have anything to send and only sent his face sheet and list of medications. LVN A stated, I was going to send the whole packet from the hospital but I thought no, we may need it when he comes back. It would not have helped the receiving hospital. It was just a list of meds and stuff. LVN A stated she called and gave report to the previous hospital Resident #1 was originally going to be taken back to, before it was changed to the local ER. LVN A stated, And then I don't know what happened after that because I passed it to the DON. LVN A stated the importance of giving the receiving hospital ER a report was to let them know why the resident was being sent out, his diagnoses, what was going on with him at the moment. LVN A stated she never followed up and contacted the local ER to give them a report on why he was sent there because she thought the DON did. LVN A stated she did not think anyone stayed with Resident #1 once he arrived at the ER. She said with non-medical transport, the driver would usually drop the resident off at the ER and let them the ER front desk know the resident was there. LVN A said she did not think Resident #1 was safe to be at the ER by himself because she thought him pulling at his three lines would still be an issue. She said normally for a resident that was not alert and oriented, the resident would have family go with them to the ER or a staff would be with the resident until family could meet them there. LVN A said the risk of Resident #1 being alone in the ER waiting room area was that he could have pulled one of his lines out and caused damage.An interview with Staff C on [DATE] at 1:47 PM revealed she was a CNA and the facility van driver and was working the day Resident #1 was sent out to the ER. She said the resident was trying to pull out his gtube and she was trying to stop him and when the paramedics came in, he calmed down. They took his vitals and said it was a non-emergency unless he pulled out his g-tube, then they could take him. Staff C stated LVN A asked for her to help with transportation, so Staff C contacted the non-emergency private transport company. She stated the typical medical transport company was too busy that day to transport Resident #1 to the ER. Staff C stated, I needed someone and he needed to go to the hospital, he was irritable, trying to pull the g-tube and he was going back to the hospital he came from. Staff C stated she and LVN A let the DON know transport was secured, got Resident #1's face sheet, got him dressed, caressed his arm and told him no one was going to harm him and she was there to assist while using her phone translator to translate into his native language, and he told her thank you back in his language. She stated she got a sheet and tucked it around his torso and he seemed to relax. Staff C stated, They saw him being fidgety but it was not an emergency for him. She stated for non-emergency transportation to the ER, a family member had to be present if the resident had a cognitive impairment and for skilled residents, the family would meet the staff at the hospital. Staff C stated with someone like Resident #1, with him being feisty, a family member would need to be present for him because of the translation barrier. She said if she took a resident to the hospital and it was a resident she knew could not be left alone and family was not present, by all means, I stay at the appointment. Staff C stated because Resident #1 did not speak English, was pulling at his g-tube and agitated, he would need someone to be with him for supervision. Staff C stated normally the charge nurse of the resident would let her know if she needed to stay with a resident at the hospital or not, but with Resident #1, she was not the driver that day, she only assisted with finding transportation. An interview with CNA D on [DATE] at 2:09 PM revealed she was present when Resident #1 was sent to the ER. She stated he was restless, fighting to push his pants off, and trying to pull out his g-tube, . She said he was saying something in another language she could not understand. She said she did incontinent care and placed a brief on him. CNA D stated there were other residents in the facility that sometimes pulled at their tubes and when they did, there was a rubber belt the facility had that could be fixed on the resident and zipped to hold the tubing in place covered and it was very hard to get into and pull off. She stated Resident #1 did not have an abdominal binder on when she saw him on [DATE]. An interview with Receptionist E on [DATE] at 3:01 PM revealed sometime during the early morning of [DATE], an unidentified nurse , told her they were sending out Resident #1. She did not ask any questions but was there to tell the EMT where to go. She said he ended up not going out 911 and did not know why, but she saw him taken out by a non-medical transport. Receptionist E stated once Resident #1 left the facility, his RP called asking why the RP was not notified or why the hospital had not contacted her yet. Receptionist E stated the RP was mad and called back again right before the shift was over saying she needed someone from higher up at the facility to email her the resident's clinicals for the ER to have for review. Receptionist E stated the RP told her the facility was going to be reported to State by the RP as well as the hospital who was filing a complaint against the facility. An interview with RN F on [DATE] at 3:27 PM reflected she was the admitting nurse at the facility on [DATE] and was told Resident #1 was admitting on her shift. He arrived on a stretcher with his RP present. RN F stated she did her nursing assessment and remembered Resident #1 was trying to pull at his tubes and not being still. She asked his RP to stay at the facility because she felt the resident needed to be watched. RN F stated the facility did not know Resident #1 had that behavior as it was not in the report from the discharging hospital. She said she knew Resident #1 was coming with an open surgical incision with a g-tube and catheter. RN F stated Resident #1 had an ace wrap on his abdomen from the hospital, not an abdominal binder, and it was not being effective. RN F said when a CNA came to sit with Resident #1 1:1, his RP left for the night. She stated the purpose of the 1:1 was to prevent the resident from rolling out of bed and to make sure he did not pull his tubes. RN F stated there was one time during her 2-10pm shift where the 1:1 CNA reported he disconnected his g-tube, which was just a connection issue. RN F said besides that one time, the 1:1 CNA did not report any other concerns to her during her shift. An interview with NP G on [DATE] at 10:14 AM revealed Resident #1 admitted after she left on [DATE] and was gone the next morning before she arrived the facility, so she never saw him. She stated she heard he was very volatile, aggressive, and punched someone the day before at the hospital. NP G stated the morning of [DATE], [LVN A ] updated me because she came into this scene and let me know it was too much, so we sent him back out. NP G said she gave a verbal order to LVN A for the ER transfer. NP G stated she got the impression from staff that Resident #1 was out of control due to agitation and confusion but she did not have a baseline to go from. NP G stated she assumed Resident #1 was sent to the ER via ambulance. She stated she did not know the EMTs assessed him and determined he did not have a medical emergency. She stated, I was not aware of that. I would not think it is safe to transport him via non-emergency because if he is actively agitated, the EMTs can handle it. That's what I thought he was doing, going out via ambulance. NP G stated if she knew the EMTs deemed him not in a medical emergency state, she would have ordered PRN medications at the facility to help address the behaviors. She stated she did not see his clinicals so she did not know if he had a qualifying diagnosis to justify their use. NP G stated giving a report to the ER when sending them a resident was important so they could know what to expect, try to prepare, and have anticipated interventions in place if they were having issues related to cardiac distress, behavioral emergency, and so forth. A follow up interview with the DON on [DATE] at 10:48 AM revealed she was notified by the facility staffing coordinator on [DATE] that LVN A felt Resident #1 was being antsy and aggressive. The DON stated she did not know until after the fact that Resident #1 had been given Haldol by the discharging hospital during his stay due to him punching a hospital staff. She said that was not sent with his hospital clinicals prior to admission. The DON stated, They didn't relay any of that information to us. They didn't tell anybody; they just were like here he's yours now. The DON said she had not observed him herself, so her decision was based on what she was told secondhand. The DON said she contacted NP G who told her to send him out to the hospital. The DON stated 911 was called but when they came out, the EMT did not feel like Resident #1 was having a medical emergency so they would not transport him to the hospital. The DON stated she did not contact NP G after EMT refused the transport to update her that the order to send out via 911 could not be done. The DON stated the information was relayed to NP G after the resident was sent out via a private transport company. The DON stated she did not consider discussing PRN medication options with the staff or NP because it could not be given to keep him subdued from pulling at his lines and it walks that fine line of are you chemically restraining a patient? The DON said with other residents in the facility with lines and pulled on them, the staff had rapport so they could more easily calm them down. The morning Resident #1 had the behaviors, [DATE], the DON stated she did not talk with his RP until after he was sent out in the private transport vehicle. The DON said she was under the impression that the RP had already been notified but did not know who did the notification. The DON said regarding sending Resident #1 to the ER via a private transport company, We felt like it was our only option.I couldn't put him in my car and take him so that was really our only recourse to get him where he needed to be. The DON said they knew the driver stayed with Resident #1 in the ER until he was checked in and gave the hospital all the information they needed before he left, Which was basically his med list. The DON said the facility did not have to supervise Resident #1 when he was taken to the ER and checked in. She stated, Technically once they leave the building they have been discharged or transferred.We ensure that they get to a place where they are safe, which we did, through a third party transport company and so at that point the hospital assumed responsibility for him once he was checked in [at the front desk]. The DON further stated she could not bill for Resident #1 so she could not send a facility staff member to sit with him since the facility would not get paid for it. An interview with the ADM on [DATE] at 11:35 AM revealed she wondered how the overnight CNA was able to manage Resident #1's behaviors during his first night of admission to the facility, And then all of a sudden it becomes this huge emergency the next morning? She stated going forward, for late night admissions, the staff needed to be more informed on what the resident's care needs were , ensure the hospital clinicals were reviewed prior to admission, and make sure interventions were in place. An interview with the private transport company, Driver H, on [DATE] at 11:47 AM revealed he remembered transporting Resident #1 by himself to the ER on [DATE]. He stated he initially started driving Resident #1 to one hospital further away but was re-routed by the facility to a closer hospital. He said when he arrived at the ER, the staff at the ER desk said to leave him there so he transferred him to a hospital wheelchair. Driver H said while in the ER waiting area, Resident #1 was trying to escape and could walk. He stated the ER staff were trying to talk to Resident #1 but he did not speak any English and they were trying to figure out what language he spoke so they could use their translator. Driver H stated he gave the ER staff the resident's face sheet, which was the only document he was given by the facility. He stated he left the hospital at that point so he did not know what else happened. A follow up interview with the ADM on [DATE] at 4:00 PM revealed the facility did not send a facility staff to supervise Resident #1 because the transport company had a driver that stayed with him. The ADM stated the only reason Resident #1 had been a 1:1 the night before was to make sure he didn't pull anything out. She stated, He [Resident #1] didn't need a 1:1 because driver of the van was with him. While he was here in the room, there was no one in the room so that is why we put an aide in. IF he had pulled out lines, the drivers are CPR trained and he was told if he needed to call 911, he could, by our nursing staff. The ADM stated the transport company said they could handle it and the company will know based on their own assessment from what we tell them, but they also observe the resident when they arrive to make sure they are appropriate [for transport]. The ADM stated, So they felt confident they could do it, we felt confident they could do it. She said the facility's responsibility for resident's supervision ended when once they were checked in at the hospital. We make sure they are there and give report and one there, they are the hospital's concern. The ADM said she felt once the DON realized that the EMTs were not going to transport Resident #1 due to him not having an emergency, maybe she felt it was not that serious of an issue and could send him out non-emergent. The ADM said she felt like the level of emergency changed when the EMTs saw Resident #1. She stated, It was not like he was in respiratory distress or about to die, so the rest of us were thinking okay, if not emergency, then next best thing. The ADM continued to state that the facility trusted the transport company to make sure the residents got from point A to point B. The ADM said she herself, talked to Driver H and he told her he stayed with Resident #1 at the ER for about 15-20 minutes until the ER staff took him to a room and she said the transport staff would never leave a patient there. The ADM stated Driver H did not tell her Resident #2 had tried to get up, rather that he sat there with him the whole time. A follow up interview with the DON on [DATE] at 4:20 PM revealed the reason Resident #1 was sent to the ER without staff supervision was because his family/RP was meeting him at the hospital. The DON did not feel that sending a staff member would have been helpful to intervene if Resident #1 had pulled at his lines during transport because that staff would be buckled in in front or behind, and not able to intervene if there was an emergency and the van was moving. The DON stated again that a resident was no longer the facility's responsibility once they left the facility when they were sent out to a higher level of care. The DON said she did not know if [Company Name] did medical transports, but there were not normally used for emergency transportations. The DON stated a staff member would accompany a resident to the ER on ly if that resident did not have a family member meeting them at the hospital. She said Resident #1 did have his family member/RP in route to meet him at the ER. Review of the facility's contract with the transport company dated, reflected in part, .l. Services Provided. (Company Name) provide patients of the Facility with nonemergency transportation services to or from locations designated by the Facility (the Services). The vehicles used by (Company Name) in the delivery of the Services shall be staffed by at least two (2) persons who are licensed or certified by law to render emergency medical care for Stretcher and Basic Life Support vehicles and at least (I) person/driver for Wheelchair Ramp and Sedan vehicles. (Company Name) shall make the Services available twenty-four (24) hours per day, seven (7) days per week, The Services do not include, and this Agreement does not affect, the delivery by (Company Name) of emergency medical transportation services. The determination of whether a transport is an emergency or nonemergency shall be made by (Company Name) in accordance with the standards and protocols established and approved by the Emergency Physicians Advisory Board.The facility's policy titled, Transfer and Discharge last revised [DATE], reflected, .7. Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident: a. Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis; b. Notify resident and/or resident representative; c. Contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements; d. Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: i. Resident status, including baseline and current mental, behavioral, and functional status and recent vital signs; ii. Current diagnosis, allergies, and reasons for transfer/discharge; iii. Contact information of the practitioner responsible for the care of the resident; iv. Resident representative information including contact information; v. Current medications (including when last received), treatments, most recent relevant lab and/or radiological findings and recent immunizations; vi. Special instructions or precautions for ongoing care to include precautions such as isolation or contact; vii. Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; viii. Comprehensive care plan goals, and ix. Any other documentation, as applicable, to ensure a safe and effective transition of care.g. Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand; h. Document assessment findings and other relevant information regarding the transfer in the medical record.This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The ADM was notified. The ADM was provided with the IJ template on [DATE] at 12:02 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:45 PM and reflected: Immediate Actions Taken (Date: [DATE]):1. None- the resident did not return after discharge.Systemic Changes Implemented:Transport Protocol:1. EMT refusal of transport will trigger an automatic notification to the physician and DON before arranging alternative transport.2. A return to acute check list for non-emergency transport was created to document resident behaviors and medical devices prior to any transfer. 3. The checklist assists staff in decision making to determine if supervision is needed during non-emergency transport for residents who are not alert and oriented and have behaviors. The determination of supervision is not just for appointments, but for any destinations, including the ER.4. A trained CNA, or Licensed nurse will be assigned to supervise transportation if supervision is deemed necessary from the checklist. The DON or Designee will arrange supervision if needed.5. The supervising staff member will stay with the resident at the ER and check them in with ER personnel.6. If there is a behavioral emergency during transport staff are instructed to pull over to a safe place, stay with the resident and call 911.Education & Training1. Regional Nurse DON/designee will educate DON on emergency transport vs non-emergency transport with posttest. Completion by [DATE]. DON/designee will educate all licensed nurses on emergency transport vs non-emergency transport with posttest. Completion by [DATE]. DON/designee will educate license nurses on the Return to Acute Checklist before calling non-emergency transport. Completion by [DATE]. DON/designee will educate CNAs on recognizing and reporting line-pulling, fidgeting, and self-harm risks immediately to the charge nurse. Completion by [DATE]. Staff unavailable to attend in service on [DATE] will receive personalized education and posttest prior to assuming their duties. Monitoring:1. DON/Designee will audit 100% of all hospital/ER transfers for 30 days to verify:a. Completion of Return to Acute Checklist for non-emergency transport.2. Findings will be reviewed in QA/QI Committee meetings monthly for 3 months, then quarterly thereafterDate Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE].Monitoring interviews for the Immediate Jeopardy were started on [DATE] at 2:45 PM with nine nursing staff and management across multiple shifts to include: DON, ADM, RN B, ADON I, ADON J, RN K, LVN L, LVN M and LVN N. All staff were able to provide competency of education on the new Resident Transfer Checklis

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the residents' choice for 3 (Resident #1, Resident #2, and Resident #3) of 8 residents reviewed for respiratory care. 1. On [DATE] RN H failed to obtain a physician's order to administer oxygen to Resident #1 when readmitted to the facility after an acute care hospital stay with the primary diagnoses of Acute on Chronic Respiratory Failure with Hypoxia (a worsening of chronic respiratory failure that can lead to hypoxia [low blood oxygen]); COPD; and CHF. 2. The facility failed to provide appropriate dispensing of oxygen by providing Resident #1 oxygen via nasal cannula (usually delivers oxygen up to 1-6 liters per minute) at levels that ranged from 7 LPM - 10 LPM on [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], LVN A failed to accurately assess for a respiratory change of condition when Resident #1 requested to go back to the hospital. 3. LVN A failed to perform adequate supervision or monitoring of Resident #1 for nearly 6 hours during his eight-hour scheduled shift on [DATE] 10:00 PM -6:00 AM ([DATE]) to oversee Resident #1 who required or received respiratory care services (i.e., oxygen therapy, ventilator/noninvasive ventilation, or nebulizer/metered-dose inhalers) to assure that Resident #1 received proper treatment and care. CNA U found Resident #1 unresponsive on [DATE] at approximately 5:05 AM. Resident #1 passed away in the facility. EMS officially declared Resident #1 dead on [DATE] at 5:23 AM. 4. The facility failed to safely handle and perform infection control practices for Resident #2's tracheostomy tubing that was dated [DATE] and was observed resting on the floor on [DATE]. 5. On [DATE], the facility failed to provide consistent oxygen therapy for Resident #3. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to all staff had not been in-serviced and the facility continuing to monitor the implementation and effectiveness of the corrective systems. These failures placed residents at the risk of not receiving enough or high levels of oxygen, which can cause difficulty breathing, result in a decline in health or possible worsening of symptoms, including death. Findings included: Record review of the nursing schedule dated [DATE] revealed LVN A [Station 3] was scheduled and worked on [DATE] 10:00 PM - 6:00 AM ([DATE]) shift. RESIDENT #1 Record review of Resident #1's 5-day MDS assessment, dated [DATE], reflected the resident was an [AGE] year-old female initially admitted to the facility on [DATE] with primary diagnoses of COPD; Pulmonary Fibrosis (a chronic lung disease that causes scarring of the lungs, making it difficult to breathe); T2DM (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar levels to be abnormally high); and Acute and Chronic Respiratory Failure with Hypercapnia (also known as CO? retention, a condition where there is too much carbon dioxide in the blood). Resident #1's most recent readmission to the facility was on [DATE] after an acute care hospital stay [[DATE] - [DATE]] - primary diagnosis at discharge included Acute on Chronic Respiratory Failure with Hypoxia (a worsening of chronic respiratory failure that can lead to hypoxia [low blood oxygen]); COPD; and CHF. Resident #1 had a BIMS Summary Score of 15, which indicated Resident #1 was cognitively intact. The 5-day MDS assessment reflected Resident #1 had shortness of breath or trouble breathing when lying flat and required respiratory treatments - continuous oxygen therapy. The 5-day MDS assessment revealed respiratory therapy was administered for 7 days in the last 7 days. Record review revealed Resident #1 did not receive end of life care, hospice, or palliative care. Resident #1 passed away in the facility on [DATE]. Record review of Resident #1's care plan, closed [DATE], reflected: [Resident #1] refused to wear BiPAP (initiated [DATE]; revised [DATE]). Goal: will be clean, well groomed, and episodes of resistance will decrease to less than weekly through the next review (initiated: [DATE]; revised [DATE]; target [DATE]). Interventions included: Monitor behavior episodes and attempt to determine underlying cause; provide positive reinforcement for tasks accomplished and when accepted needed assistance (initiated [DATE]). [Resident #1] is on Antibiotic Therapy r/t infection. (Initiated [DATE]; cancelled [DATE]). Goal: will be free of any discomfort or adverse side effects of antibiotic therapy through the review date (initiated [DATE]; Target date [DATE]; cancelled [DATE]). Interventions included: Administer medication as ordered (Initiated [DATE]); encourage coughing and deep breathing exercises (Initiated [DATE]); Observe for possible side effects every shift. (Initiated [DATE]). [Resident #1] used oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. (Date initiated: [DATE]). Goal: [Resident #1] will have no s/sx of hypoxia (poor oxygen) through the next review date (Date initiated: [DATE]; Target Date: [DATE]). Interventions included: Administer oxygen therapy per physician's orders; Monitor for s/sx of respiratory distress and report to MD PRN; Encourage resident to change position at least every two hours to promote lung expansion and to facilitate secretion movement and drainage; Position with head of bed elevated whenever possible to allow for optimal lung expansion and gas exchange. (Initiated: [DATE]) Respiratory Status: Impaired. [Resident #1] had impaired respiratory status and is at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia. This is related to a diagnosis of COPD. (Date initiated: [DATE]). Goal: [Resident #1] will have no reports of unrelieved shortness of breath through the next review date (Date initiated: [DATE]; Target Date: [DATE]). Interventions included: may use BiPAP with home settings (Initiated: [DATE]); Administer medications as ordered; Monitor for shortness of breath, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions. Notify physician if interventions are not effective; Encourage and remind resident to use call light to call for assistance. Instruct resident to report any shortness of breath immediately (initiated [DATE]). Record review of Resident #1's Order Summary Report, printed [DATE], reflected: - Verbal Order date - [DATE]: May see [telehealth] Physician PRN. - Verbal Order date - [DATE]: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 mL) inhale orally every four hours as needed for Shortness of Breath, Wheezing. [DISCONTINUED on [DATE]] - Prescriber Entered Order date - [DATE]: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 mL) inhale orally via nebulizer one time only for wheezes throughout; rhonchi bilateral lobes posterior r/t Acute and Chronic Respiratory Failure with Hypoxia and COPD until [DATE]. - Prescriber Entered Order date - [DATE]: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 mL) 0.083% (Albuterol Sulfate) 2.5 mg inhale orally via nebulizer four times a day for fluid in lungs r/t COPD until [DATE]. - Phone Order date - [DATE]: Chest x-ray (CXR) for cough related to COPD exacerbation. [COMPLETED] - Prescriber Entered Order date - [DATE]: Azithromycin ([antibiotic] used to treat certain bacterial infections) Oral Tablet 500 mg by mouth one time a day for fluid in lungs until [DATE]. - Prescriber Entered Order date - [DATE]: Azithromycin Oral Tablet 250 mg by mouth one time a day for fluid in lungs until [DATE]. - Prescriber Entered Order date - [DATE]: CBC, CMP STAT r/t COPD with exacerbation. [COMPLETED] - Prescriber Entered Order date [DATE]: Furosemide (a strong diuretic [water pill]) Oral Tablet 20 mg. Give 20 mg by mouth three times a day r/t COPD until [DATE]. - Verbal Order date - [DATE]: Full Code - Verbal Order date - [DATE]: Inspect external O2 filter weekly. Clean/change if needed every night shift every Wednesday for oxygen use. - Verbal Order date - [DATE]: Inspect external O2 filter weekly. Clean/change if needed every night shift for delivering clean oxygen. - Verbal Order date - [DATE]: BiPAP (a noninvasive form of mechanical ventilation delivered through nasal or full-face masks with inspiration (inspiratory positive airway pressure - [IPAP]) and exhalation pressures (expiratory positive airway pressure - [EPAP]) at 12 cm H2O Inspiration and 5 cm H2O Expiration with Oxygen at 5 LPM without humidification. BiPAP scheduled start at bedtime for sleep apnea related to Pulmonary Fibrosis, uns; COPD, uns. Discontinue upon waking. - Verbal Order date - [DATE]: Wipe down the mask, tubing, and machine after each use. Clean the machine, humidifier, mask, and tubing per the manufacturer's recommendations or weekly in the morning for sleep apnea. - Verbal Order date - [DATE]: Change Nebulizer tubing and administration device weekly. Clean/change the nebulizer filter every night shift every Monday for delivering oxygen in clean tubing. Ensure that tubing is dated when changed. - Verbal Order date [DATE]: Change O2 tubing, and humidifier bottle every night shift every Monday. Ensure that tubing is dated when changed. - Verbal Order date [DATE]: Change O2 tubing, and humidifier bottle every night shift for oxygen delivery system hygiene. - Verbal Order date - [DATE]: Incentive Spirometry. Assist/instruct resident to place the mouthpiece in the mouth, sealing lips around it, and breathe in as slowly and deeply as possible, trying to raise the piston towards the top of the column. Instruct them to hold their breath as long as possible before exhaling for 10 repetitions and 4 sets. Encourage the resident to cough between breaths. - Verbal Order date - [DATE]: Monitor respirations and oxygen saturation while using CPAP/BiPAP every 4 hours for sleep apnea. - Verbal Order date - [DATE]: O2 at 9 LPM via NC. Monitor O2 Saturation. Notify physician if SpO2 ([oxygen saturation], a measurement of the percentage of oxygen in the blood relative to its maximum capacity) falls below 90% every shift. [DISCONTINUED [DATE]] - Verbal Order date - [DATE]: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 mL) 0.083% (Albuterol Sulfate). 1 vial inhale orally every four hours as needed for Shortness of Breath r/t Acute and Chronic Respiratory Failure with Hypoxia. - Prescriber Entered Order date - [DATE]: Nursing: [Resident] to do I/S after each nebulizer treatment. Goal is to pull 2000 mL. Device at bedside. Four times a day for mobilization of secretions related to COPD. - Phone Order date - [DATE]: STAT Chest x-ray r/t cough. [DISCONTINUED] - Verbal Order date - [DATE]: STAT Chest x-ray r/t fluid overload. [DISCONTINUED] - Prescriber Entered Order date - [DATE]: CBC, CMP STAT r/t Acute and Chronic Respiratory Failure with Hypoxia; COPD with exacerbation. [COMPLETED] - Phone Order date - [DATE]: STAT BNP (blood test about how heart is working by measuring the levels of the BNP protein in the bloodstream) r/t fluid overload. [DISCONTINUED] - Verbal Order date - [DATE]: O2 at 5 LPM via NC. Monitor O2 Saturation. Notify physician if SpO2 falls below 90%. - Prescriber Entered Order date - [DATE]: Levofloxacin ([antibiotic] used to treat bacterial infections) Oral Tablet 500 mg. Give 500 mg by mouth one time a day for PNA (pneumonia) until [DATE] for 5 days. - Prescriber Entered Order date - [DATE]: Methylprednisolone ([a steroid] used to treat inflammatory conditions and respiratory disorders) oral tablet 4 mg. Give 4 mg by mouth two times a day for fluid in lungs r/t Acute and Chronic Respiratory Failure, COPD until [DATE]. Record review of Resident #1's [DATE] eMAR/eTAR, printed [DATE], reflected Methylprednisolone 4 mg tablet ordered to start [DATE] at 4:00 PM was not administered; Levofloxacin 500 mg tablet ordered on [DATE] was not started; oxygen ordered on [DATE] at 9 LPM via NC and [DATE] at 5 LPM via NC were not initialed by a nurse that indicated oxygen was administered. Albuterol Nebulizer treatments were scheduled at 8AM, 12 PM, 4 PM, and 8 PM. The [DATE] eMAR/eTAR did not reflect PRN Albuterol nebulizer treatments (ordered [DATE]; discontinued [DATE]) initialed by a nurse or LVN A that indicated a PRN nebulizer treatment was administered on [DATE] or [DATE]. Record review of Resident #1's Readmit Evaluation, dated [DATE], RN H documented Admitting Diagnosis Acute on chronic Respiratory Failure with Hypoxia, Chronic Pulmonary Edema. Vitals ([DATE] at 8:30 PM): BP 115/66; HR 69; Respirations 18. No cough. Breath sounds were clear bilaterally, no shortness of breath noted while lying, sitting, or on exertion. Uses Oxygen at 4 LPM via NC. No sleep aids. Record review did not reflect physician orders for oxygen administration. Record review of Resident #1's progress notes reflected: Alert Note entered by RN H on [DATE] at 9:07 PM, Readmit from [Hospital] via stretcher by 2 paramedics for continued care under [PCP] with the diagnosis of Acute on chronic respiratory failure with hypoxia and Chronic Pulmonary Edema. Head to toe assessment completed. (Vital signs measured - BP, P, R, T), O2 sat 95% on O2 at 4 LPM via nasal cannula, no respiratory distress noted. [PCP] notified of [Resident #1] arrival, [PCP] said to continue hospital transfer orders and to use standard sliding scale for regular insulin. Alert Note entered by LVN A on [DATE] at 11:30 PM, Report received from outgoing nurse (RN H) that [Resident #1] refused the BiPAP and would like it applied later. [Resident #1] refused again. WCTM. Alert Note entered by LVN A on [DATE] at 1:00 AM, [Resident #1] refused the BiPAP again. WCTM. Alert Note entered by LVN A on [DATE] at 4:22 AM reflected, [Resident #1] told this nurse [LVN A] to call [Resident #1's daughter] and inform that [Resident #1] was going back to the hospital. [LVN A] asked [Resident #1] why was she going to the hospital and [Resident #1] responded I don't know. [LVN A] indicated that Resident #1's oxygen level was difficult to read due to fingers and toes were too cold. Eventually, a 63% [O2 sat] resulted. LVN A indicated that he turned off the fan and covered [Resident #1] entire body up with blankets and obtained a (90% O2 sat) in less than 2 minutes. [Resident #1] stated, 'I was very cold. This feel better'. With resident calm, [LVN A] left the room and returned in about 5 minutes, gave resident her due medication (omeprazole 20mg) and oxygen level re-checked at 99. [Resident #1] denied having a breathing problem and responded yes when asked if she could see her oxygen level in the pulse ox. WCTM. Physician Progress Note entered by NP N (effective date: [DATE] 1:09 PM), New patient [Resident #1] here for COPD exacerbation and needing BiPAP; refusing. [Resident #1] says she feels shortness of breath just sitting up in bed with O2 at 3 LPM per NC. [Resident #1] clarified she does not 'refuse' the BiPAP, but that it makes her nose run and it gets in her mouth, making her feel like she's choking. Auscultated (heard by listening with a stethoscope) wheezes throughout and rhonchi in posterior lobes. c/o anxiety and shortness of breath. Assessment: Wheezes heard throughout; rales heard in both lower lobes posteriorly; [Resident #1] is short of breath just sitting and becomes 'more short' of breath and labored respiration when moves in bed. Alert Note entered by LVN A on [DATE] at 11:45 PM, [Resident #1] refused BiPAP. No SOB noted. WCTM. No Daily Skilled Note entered on [DATE]. Alert Note entered by LVN A on [DATE] at 5:46 AM, [Resident #1] is calm and with eyes closed. On continuous oxygen at 10 LPM via nasal canula and tolerating well. Nursing Note entered by LVN J on [DATE] at 11:12 AM, [NP N] in the building this shift doing rounds. New order per NP N for CXR due to COPD exacerbation. Order faxed to [mobile diagnostic]. Alert Note entered by RN H on [DATE] at 4:58 PM, Following chest x-ray result, [Resident #1] was placed on Zithromycin 500 mg by mouth, 1 dose today followed by 250 mg daily by mouth for four days for fluid in the lungs and nebulizer treatment every four hours. Order initiated. Family visiting, aware of new order. Alert Note entered by LVN I on [DATE] at 11:17 PM, [Resident #1] c/o SOB and had all her clothes off saying she is very hot and want to go back to the hospital. Vitals were T 97, P 82, R 18, BP 122/78, O2 sat was 78% via NC at the maximum (An oxygen concentrator can generate up to 15 liters of oxygen per minute. A nasal cannula usually delivers oxygen up to 1-6 liters per minute. A simple face mask is necessary to deliver oxygen at a flow rate of 6-10 liters per minute). [LVN I] remained at [Resident #1] bed side to reduce [Resident #1] anxiety. [Resident #1] was reassured dressed warm and nebulizer treatment was administered. After treatment, O2 sat was 97%. [Resident #1] showed sign of relief and went to sleep. WCTM. Physician's Note entered by NP N dated [DATE] (effective date: [DATE] 5:45 AM), CXR late yesterday revealed fluid in most lobes. Per nurse, [Resident #1] is on 10 LPM O2 via NC with O2 sats at 97%. Nurse says [Resident #1] is moving around a lot, had taken off her clothes earlier in the night and O2 sats were found to be 79%. After clothes were placed back on by nurse, O2 sats increased to 95% on 10 LPM O2 per NC. No Daily Skilled Note entered on [DATE]. Daily Skilled Note LATE ENTRY entered by RN B dated [DATE] at 11:28 AM, [Resident #1] requires daily skilled observation for respiratory issues. Respiratory rate is regular. Has shortness of breath noted with exertion. Shortness of breath present when lying flat. Oxygen therapy utilized. Nebulizer treatment was administered. [Resident #1] was repositioned to alleviate SOB. Wheezes are noted upon auscultation of breath sounds. No cough noted this shift. [Resident #1] on O2 at 7 LPM via BiPAP. Daily Skilled Note entered by RN B on [DATE] at 10:45 AM, [Resident #1] requires daily skilled observation for respiratory issues. SpO2 at 96% with oxygen in place. Respiratory rate is regular. No shortness of breath noted this shift. Lungs are clear. No cough noted this shift. Resident on O2 at 7 LPM via BiPAP. OTHER OBSERVATIONS: Dyspnea on exertion. Daily Skilled Note entered by LVN J on [DATE] at 11:15 AM, [Resident #1] requires daily skilled observation for cardiac issues, circulatory issues, teaching/education. SpO2 at 95% on room air with oxygen in place. Respiratory rate is regular. No shortness of breath noted this shift. Lungs are clear. No cough noted this shift. [Resident #1] on O2 at 3 LPM via NC. No changes were noted to the resident's respiratory status. Record review of lab results dated [DATE] at 11:03 AM revealed CO2 (bicarbonate) levels 40.0 HIGH (normal range: 22.0 - 29.0). Record review of Resident #1's progress notes reflected: Lab Note entered by LVN J on [DATE] at 1:53 PM, Lab results in for CBC and CMP. Reviewed by NP N. No new orders. Physician Progress Note entered by NP N (effective date: [DATE] 2:22 PM), Follow up visit for COPD exacerbation. [Resident #1] on 9 LPM 02 via NC with 02 sats at 96%. Nurse says [Resident #1] is yelling out a lot saying she 'can't catch my breath'. Per night shift nurse 97% on 10L O2. [Resident #1] appears anxious. Physician Progress Note entered by NP N (effective date: [DATE] 4:16 AM), [PCP L] informed of [Resident #1's] condition. [PCP L] saw [Resident #1] suggested to give medication by mouth and to cancel midline. Physician Progress Note entered by NP N ([Addendum] effective date: [DATE] 6:09 AM), Lab results show [potassium] 4.0 and WBC 9.1. Will continue round of antibiotics and continue with Lasix and potassium replacement. Physician Progress Note entered by NP N dated [DATE] at 12:13 PM, Follow up visit for COPD exacerbation. Pt is on 9 LPM O2 via NC with O2 sats at 96%. [Resident #1] says she is feeling the same as yesterday. Shown how to do IS (incentive spirometer) properly. Wheezes heard throughout; is SOB with exertion and becomes more SOB when [Resident #1] panics. Rales heard in middle lobes posteriorly, crackles heard in base of posterior left lobe. Physician Progress Note entered by NP N dated [DATE] at 2:47 PM, [Resident #1] has wheezes, rales throughout. Crackles in both bases, more in left lower base. [Resident #1] has been on 9 LPM per NC with O2 sat of 96%, although, [Resident #1] has been unable to rest, is agitated, becomes 'more short' of breath with minor position change. 2 IV attempts made to left arm, unsuccessful. Right arm has Do Not Use bracelet on. Midline has been ordered STAT. CXR, BNP, CBC, CMP ordered STAT. Physician Progress Note entered by NP N dated [DATE] 4:12 PM, [PCP L] made aware of [Resident #1's] condition. [PCP L] saw [PCP L] suggested midline IV be cancelled. [PCP L] stated medication by mouth would be just as effective as IV. Midline cancelled. IV methylprednisolone cancelled and ordered by mouth. Alert Note entered by RN H on [DATE] at 7:09 PM, [Resident #1] seen by [NP N] during rounds and started on a lot of orders for the diagnosis of Pneumonia, fluid overload, acute and chronic respiratory failure with hypoxia not limited to Dexamethasone 4 mg, 1 tab by mouth twice daily until [DATE], STAT BNP, CBC, and CMP. Levaquin 500 mg 1 tab PO daily until [DATE], check vital signs after each nebulizer treatment and to do incentive spirometry after each treatment goal to pull 2000 mL. [Resident #1's] son at bedside, aware of new orders. Alert Note entered by RN H on [DATE] at 7:39 PM, Lab here STAT CBC, CMP and BNP drawn per order. Record review of lab results dated [DATE], collected at 7:24 PM, revealed a critical result was called to the facility and accepted by RN H at 9:26 PM. The results were faxed to the facility at 10:45 PM. The results revealed CO2 (bicarbonate) levels > (greater than) 45.0 HIGH PANIC (normal range: 20.0 - 31.0). Record review of Resident #1's progress notes reflected: Alert Note entered by RN H effective date [DATE] at 8:08 PM, Lab called with critical CO2 same called to on call, said to continue treatment, that has Pneumonia, and she is already on antibiotics. Assisted with using I/S and nebulizer treatment per order, tolerating well. Dexamethasone not available, awaiting pharmacy delivery. Report given to night nurse to follow up with STAT labs and STAT chest x-ray. [On call telehealth] Health Note entered by APN K dated [DATE] 1:13 AM (Effective Date: [DATE] at 10:01 PM), Details: Nurse Name (RN H). Primary Chief complaint: Lab Review. Abnormal results requiring provider assessment. Received critical CO2 lab result. Result reveals CO2 level of >45. [Resident #1] has pneumonia and is on antibiotic. Reviewed past medical history and medications. Per nurse Vitals T 97; HR 76; BP 108/65; Respirations 20; SpO2 94%. Physical exam findings per nurse and video observation. Orders: continue to monitor pt. Disposition: Stay at facility. Technology used: Audio and video with patient and nurse present. Alert Note entered by LVN A on [DATE] at 11:04 PM, Radiology report received, Moderate bilateral scattered pneumonias. Report forwarded to [APN K, on call TeleDoc provider]. No new orders. [Resident #1] already on treatment for pneumonia, per APN K. No Daily Skilled Note entered on [DATE]. [On call telehealth] Health Note entered by APN K dated [DATE] 2:11 AM (Effective Date: [DATE] at 11:02 PM), Details: Nurse Name (LVN A). Primary Chief complaint: Radiology review. Abnormal results requiring provider assessment. Received chest x-ray result. Result reveals moderate bilateral scattered pneumonias. Pt already started on Levaquin 500 mg one time daily today. [Resident #1] VSS. Reviewed past medical history and medications. Per nurse Vitals T 97.4; HR 67; BP 134/68; Respirations 16; SpO2 95%. Physical exam findings per nurse and video observation. No new order. Will continue to monitor pt. Disposition: Stay at facility. Technology used: Audio and video with patient and nurse present. Alert Note entered by LVN A on [DATE] at 7:06 AM (Effective date: [DATE] at 1:00 AM), Resident in bed resting. No form of distress noted. Oxygen at 10 LPM in continuous use with nasal cannula in place. Respiration even and non-labored. WCTM. Alert Note entered by LVN A on [DATE] at 07:27 AM (Effective date: [DATE] at 2:45 AM), Rounds made and resident is awake and requested for a breathing treatment which this nurse administered and waited for the treatment to be completed. O2 sat after the treatment was 95%. This nurse exit the room around 3:04 AM. Alert Note entered by LVN A on [DATE] at 8:17 AM (Effective date: [DATE] at 4:50 AM) indicated that [LVN A] was called to the room that resident is unresponsive. This nurse left the med pass and went with the staff. Code blue is called and CPR started. A nurse called 911 and 2 policemen came followed by the emergency crew which pronounced resident dead around 0515. The nurse that called 911, also informed this nurse that the family had been notified and were on their way to the facility. The policemen obtained information, needed and gave a report number. The policemen gave the medical examiners numbers to this nurse to call, that the examiner is waiting on the call. This nurse called the medical examiner and was issued a report number. Alert Note entered by LVN A effective date [DATE] at 8:29 AM, DON and ADON aware. Physician Progress Note entered by PCP effective date [DATE] at 12:15 PM, Service date: [DATE], Pt seen today as routine visit. All recent notes and documents were reviewed; all recent vital signs and labs were reviewed; all medications were reviewed; no issues or concerns per nursing except for pt refusing CPAP at night. Pt was just hospitalized ; does not feel like her breathing is improving; pt appears in no distress but condition is guarded. Document e-signed by PCP on [DATE] at 10:15 AM. Record review of the F.D. Care Report dated [DATE] reflected a call date and time, [DATE] at 5:13 AM for a Cardiac Arrest - Possible DOA. The response mode was Emergent (Immediate Response) to the facility. The arrival time at scene was 5:20 AM and at Resident #1, 5:22 AM. The Care Report narrative reflected, [EMS] arrives on scene [at facility] and finds [Resident #1] lying in bed with facility staff performing CPR. EMS takes over and assesses. [Resident #1] has no pulse and has signs incompatible with life (Rigor and dependent lividity) [considered early postmortem changes that occur 3 to 72 hours after death]. Resuscitation efforts discontinued and [Resident #1] declared dead on scene. EMS clears from scene. The disposition reflected Patient Dead at Scene - No Resuscitation Attempted. EMS departed at 5:34 AM. Record review of the P.D. Incident Report dated [DATE] at 6:38 AM, the officer's [Officer V] narrative reflected officers were dispatched to the facility on [DATE] at 5:14 AM. Upon arrival, officers observed [LVN A] performing CPR on [Resident #1] who was lying fully dressed, on her back, in her bed. [LVN A] advised Officer V that approximately 3:00 AM ([DATE]), LVN A had gone to Resident #1's room to give oxygen. LVN A stated that Resident #1 was in good health, with no apparent complications. At approximately 5:00 AM ([DATE]), CNA U made her last checkup rounds before end of shift at 6:00 AM. CNA U found [Resident #1] to be unconscious and not breathing. CNA U immediately called for LVN A, at which point [LVN A] began to perform CPR on Resident #1 and shortly thereafter officers arrived on scene. Officer V spoke with CNA U who advised the same exact story. The F.D. arrived on scene and declared the time of death at 5:23 AM ([DATE]). Record review of the Detective's Clearance Statement dated [DATE] at 1:08 PM reflected, On [DATE] [Detective] reviewed the unattended death of [Resident #1]. [Detective] spoke with [family member] who described Resident #1 cold to touch upon arrival to facility after notification that Resident #1 passed away. [Family member] stated that there was video that revealed LVN A did not check on Resident #1 at 3:00 AM. Video was received from [family member] and reviewed. The video did not reveal that any staff appeared to check in on [Resident #1] (at approximately before or after 3:00 AM) until found deceased ([DATE] after 5:00 AM). During an interview on [DATE] at 11:50 AM, the MOD stated he was the RN weekend supervisor, 6A - 10P. The MOD said that he recalled Resident #1 and described her as able to verbalize wants and needs, received oxygen continuously, but was unaware of any respiratory distress during the weekend of [DATE] and [DATE]. The MOD said that [Resident #1] often complained about shortness of breath and if her O2 sat levels were below 88% with oxygen, [Resident #1] would be sent to the hospital. The MOD said other respiratory changes of condition included, difficulty speaking or gasping due to breathing difficulty; tightness in chest; or unresolved wheezes with breathing treatment. An attempt to interview PCP L by telephone on [DATE] at 11:58 AM was answered and routed to an automated system with hospital options. Unable to leave message. During an interview on [DATE] at 12:25 PM, the complainant stated that the police responded to a 911 call on [DATE] for a resident who was unresponsive. The complainant stated based on interviews and video evidence of the incident, the night nurse did not check on Resident #1 every two hours or provided treat[TRUNCATED]