**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident received, and the facility provided, care and services consistent with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 4 residents (R1) reviewed for change of condition. On [DATE], R1 presented with a change of condition including weakness, abnormal lung sounds, a fever of 102.6, cough, influenza positive, and shortness of breath. As the day progressed, R1 continued to deteriorate with increased symptoms of difficulty breathing and weakness. The facility failed to complete a comprehensive nursing assessment by a registered nurse and failed to consult with a physician even as R1's condition continued to deteriorate. R1 expired at the facility on [DATE] at 11:58 PM. The facility's failure to complete a comprehensive nursing assessment and notify the physician with a change of condition created a finding of Immediate Jeopardy beginning on [DATE]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the finding of Immediate Jeopardy on [DATE] at 5:15 PM. The immediacy was removed on [DATE] and continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. The facility's policy titled SNF (Skilled Nursing Facility)/Sub-Acute Condition Change Reporting dated 1/2024 states in part: Policy: Communication with the physician is maintained with healthcare professionals, the resident/patient, family, and/or significant other(s) when a change in a resident's/patient's condition affects the current level of his/her care. 1. The physician, resident/patient, and/or family are notified when the resident's physical, communicative, psychosocial, or functional status changes unexpectedly, the resident is injured, or if treatment is significantly altered. 2. If nursing staff is unable to reach the resident's/patient's attending physician, the facility medical director of the physician on-call will be notified. 3. If there is a question by nursing about the appropriateness of physician follow-up, the Director of Nursing and Administrator are notified .5. The resident's/patient's condition and the notification of residents/patients [sic] chosen representative, and physician must be documented in the EMR (Electronic Medical Record) medical record. The facility's policy titled [Facility Name] SNF Assessments dated 1/2024 states in part: .Policy: Assessment will occur prior to an admission, upon admission, quarterly, and upon significant change. Assessment findings will be documented, the attending physician notified as applicable and a plan of care will be initiated or updated to reflect findings .Changes in Resident Condition In the event that a resident's physical, mental, or psychosocial status changes; or if there is a significant change or an injury occurs, the attending physician, other authorized healthcare professionals and family/guardian will be notified. An RN (Registered Nurse) or MD (Medical Doctor) will perform an assessment, and the findings will be documented in the nursing notes. R1 admitted to the facility on [DATE] with diagnoses that include end stage renal disease requiring hemodialysis (a procedure that involves passing blood through a filter to remove waste and extra fluid), congestive heart failure (a chronic condition where the heart can't pump blood well enough to give the body a normal supply), and left ankle fracture. R1's Brief Interview for Mental Status dated [DATE] has a score of 15 indicating R1 is cognitively intact. R1's nursing progress notes state the following: [DATE] at 1:36 AM 0030 (12:30 AM) pt (Patient) up to BR (Bathroom), per CNA (Certified Nursing Assistant) more difficult to transfer than normal, pt c/o (Complained Of) being SOB (Shortness of Breath) with transfer, breathing noted to be regular, even. LUL (Left Upper Lobe), RUL (Right Upper Lobe) CTA (Clear to Auscultation), bilateral lower lobes unable to hear, no cough noted, per pt states she was coughing during day and reports bright yellow sputum. Denies dizziness. Vitals taken, Temp (Temperature) elevated Tylenol last given at 2221 (10:21 PM) for headache, SPO2 (percentage of oxygen in the blood) on 2l (Liters)/via n/c (nasal cannula) was 88-89%. O2 (supplemental oxygen) increased to 3l/min for 30min (minutes) SPO2 at 96%, decreased O2 back to 2 liters Secure chat (electronic portal to communicate with physician similar to a direct message on a phone) sent to MD (Medical Doctor). Pt resting quietly in bed at this time with eyes closed, will continue to monitor. Electronically signed by RN G at [DATE] 1:46 AM [DATE] at 8:46 AM - CNA reports to this RN (Registered Nurse) that pt seems off this morning. Pt has wet, productive deep cough and her mental status seems off. She is struggling to answer simple questions, has fever and cough and her functional decline in transfers and ADLs (Activities of Daily Living) has deteriorated since Friday. Temp is elevated at 102 this AM, BP (Blood Pressure) 153/67 and is currently on 2L of O2. She is weak and lethargic at this time. I know she recently started on Metolazone (medication used to treat high blood pressure and fluid retention). Lungs sounded course and diminished in LLL (Left Lower Lobe), RLL (Right Lower Lobe), LUL (Left Upper Lobe). Chat sent to MD. Electronically signed by RN H at [DATE] 11:33 AM Of note, [DATE] at 8:46 AM is the last documented RN assessment for R1. [DATE] at 9:14 AM - Per protocol COVID swab obtained. Resulted negative. Electronically signed by DON B at [DATE] 9:14 AM [DATE] at 9:16 AM - Per RN staff, patient had difficulty performing a stand pivot transfer wheelchair to toilet on this date due to difficulty following commands. Patient's chart reviewed. Patient sitting in recliner with supplemental oxygen donned and sleeping. Patient awoke enough to state she was feeling lousy but then immediately fell back to sleep and didn't answer any other subsequent questions. Patient mouth breathing and appeared SOB. Discussed concerns with RN [Name] and DON B. Will hold PT (Physical Therapy) treatment session on this date as patient is not medically appropriate and unable to stay alert enough . Electronically signed by PT I (Physical Therapist) at [DATE] 9:26 AM [DATE] at 10:10 AM - VM (Voicemail) and Email sent to [Assisted Living Name] - R1 is not feeling well today so assessment will need to be rescheduled . Electronically signed by SW J (Social Worker) at [DATE] 10:11 AM [DATE] at 12:35 PM - Pt not feeling well this afternoon with temp per nursing. Upon room entry pt also visibly shaking and stated she was not feeling well. Will reattempt to see for skilled OT (Occupational Therapy) services at later date as pt able. Electronically signed by COTA K (Occupational Therapy Assistant) at [DATE] 1:03 PM [DATE] at 1:08 PM - MD notified of critical lab. NOR (New Order) received for CXY (Chest X-ray) and Resp (Respiratory) panel. Electronically signed by RN H at [DATE] 11:38 AM Of note, R1's change in condition started 12.5 hours prior to the first documented consultation with a physician that included interventions. Of note, DON B (Director of Nursing) indicated the critical lab reported was the Influenza A1H3 positive result. [DATE] at 4:25 PM - Critical Lab reported to MD. Resp panel positive for Influenza A1H3 . Electronically signed by RN H (Registered Nurse) [DATE] 4:25 PM [DATE] at 6:30 PM - .Summary of physical status and trends R/T (Related To) skilled service: . Pt. Has had SOB, fever, and crackles to RUL (Right Upper Lobe) and bilat (Bilateral) LL (Lower Lobe) are both diminished. Pt had CXR (Chest X-Ray) and full resp panel. Pt Is pos. (Positive) For Influenza A1H3. Pt. Wheezing bilateral UL (Upper Lobe). Albuterol inhaler (medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing and chest tightness) not affective [sic] as pt is SOB and unable to accurately use her inhaler . Electronically signed by LPN L (Licensed Practical Nurse) at [DATE] 7:47 PM [DATE] at 7:08 PM - New set of v/s (Vital Signs) obtained. Spot [sic] 92 2LN/C B/P 186/66, P100 Temp 102.6 MD notified. Electronically signed by LPN D at [DATE] 5:56 PM On [DATE] at 12:53 PM, Surveyor interviewed LPN D regarding notification of MD. LPN D indicated MD notification was sent via secure chat (an electronic portal to communicate with the physician) and LPN D did not speak to and did not consult with a physician. [DATE] at 9:45 PM - Received a call from the nurse stating patient had developed a fever, seemed to be having more difficulty breathing and weaker. Nurse stated he had called MD [Name] but could not get a hold of him. Writer advised nurse to call NP [Name] (Nurse Practitioner) and update her. Writer received no phone call after that and was not aware that nurse was unable to reach NP [Name]. Electronically signed by RN C at [DATE] 12:54 AM [DATE] at 10:11 PM - Resident noted with temperature of 102.6, increased difficulty breathing, increased weakness. Calls with messages placed to MD [Name] and NP [Name]. Awaiting callback. House supervisor (RN C) aware of change in condition. PRN (As needed) nebulizer (a small machine that turns liquid medicine into a mist that can be inhaled through a mouthpiece or mask) administered as ordered. Medication was effective. Mouth care performed. Resident declined any other medications/cares at this time. Electronically signed by LPN D at [DATE] 10:17 PM [DATE] at 12:01 AM - I went into resident's room (2330hrs) (11:30 PM) to monitor her. It appeared resident's [sic] wasn't breathing, resident's fingers where [sic] blue in color and her mouth was fixed in an open position. I called the house supervisor (RN C) who gave me the on-call Doctor number which, I called. The doctor came up and pronounced the resident at 2358hrs (11:58 PM). Electronically signed by LPN D at [DATE] 6:46 AM [DATE] at 1:16 AM - When I went into resident's room at 2330hrs (11:30 PM) it appeared that resident's [sic] was not breathing, resident was rigged [sic], finger tips where [sic] blue in color and cold on both hands and her mouth was fixed in an open position. I looked for the rise and fall of resident chest and saw no movement. I felt for resident's radial pulse and felt no pulse I spoke with the aide (CNA E) who stated that she had just looked-in-on the resident at 2250hrs (10:50 PM) I then walked back to the nursing station and called the House Supervisor (RN C) who gave me the number for Doctor [Name]. I called Doctor [Name]. Electronically signed by LPN D at [DATE] 1:28 AM On [DATE] at 12:53 PM, Surveyor interviewed LPN D (Licensed Practical Nurse) regarding R1's change in condition. LPN D gave the following timeline for his shift on [DATE] in regard to R1: 6:30 PM LPN D arrived to the unit. LPN D was unable to get shift report from the LPN L right away, so LPN D printed his resident list and started making rounds. 6:45 PM LPN D entered R1's room and noticed R1 was not doing well. R1 was sweaty, having difficulty breathing, and her words were a light whisper when she spoke. LPN D indicated R1 sounded gurgly like she had phlegm in her mouth. LPN D directed CNA F to obtain vital signs. 7:00 PM LPN D received shift report from the LPN L. LPN D stated LPN L reported R1 had a chest x-ray and respiratory panel completed which indicated R1 was positive for Influenza. LPN D indicated LPN L had received an order for a nebulizer treatment and LPN L was going to enter the order into the electronic medical record. LPN D indicated he received R1's vitals, sent a secure chat to the doctor because of R1's status and contacted the respiratory department to obtain the supplies for the nebulizer. 7:30-8:00 PM LPN D indicated he gave R1 the nebulizer treatment, he raised R1's head of the bed and ensured the supplemental oxygen was in place. LPN D said he did not listen to her lungs when he gave the nebulizer treatment. 8:30-9:00 PM LPN D offered R1 her bedtime medications and R1 refused. LPN D indicated he called RN C because he was unable to get a hold of the doctor. LPN D indicated RN C gave him the doctor's direct number and told LPN D to call the NP if he was unable to contact the doctor. LPN D indicated he called the doctor and NP and was not able to speak with either of them. LPN D indicated he was calling the doctor because LPN D thought R1 needed a higher level of care than he could provide to address her change in condition. It should be noted at no time did LPN D ask R1 if she wanted to be sent to the emergency room or did LPN D send R1 due to R1's significant change of condition and decline. LPN D continued the timeline for his shift: 11:30 PM LPN D entered R1's room. LPN D stated R1 was not breathing, mouth was fixed in an open position. R1's fingers were blue and cold on both hands. LPN D indicated R1's arm was stiff and rigid when he moved R1's arm to check for a radial pulse. LPN D stated he was unable to obtain a pulse. LPN D stated there was no rise and fall of R1's chest when he checked for respirations. LPN D indicated he called RN C to notify her of R1's passing, and RN C instructed him to call the on-call doctor. LPN D called the on-call doctor for notification of R1's passing. During the interview, LPN D indicated he did not speak to a physician regarding R1's condition and did not have an RN assess R1 prior to R1 passing. On [DATE] at 1:00 PM, Surveyor interviewed CNA F regarding R1's condition on [DATE]. CNA F indicated LPN D asked her to obtain R1's vital signs. CNA F said R1 was having a hard day. CNA F indicated R1 was breathing fast and was too weak to transfer and use the toilet and had to use a bed pan instead and CNA F reported that to the nurse. CNA F stated she obtained the vital signs and gave the results to LPN D. On [DATE] at 4:56 PM, Surveyor interviewed RN C. RN C indicated she is the house coordinator-shift supervisor for the hospital that is connected to the nursing home. RN C indicated she recalls the events related to R1 on [DATE]. RN C stated she received a call from LPN D but did not recall the time. RN C indicated LPN D told her he was unable to get a hold of the doctor and LPN D wanted to let the MD know he had a resident who had a fever and increased difficulty breathing. RN C stated she told LPN D if he was unable to contact the doctor then he should call the NP. RN C indicated she was unaware LPN D did not get a hold of the doctor or NP since LPN D did not call her again regarding this. RN C indicated she did not hear from LPN D again until later that night when LPN D reported he had a resident who passed away and needed to contact a doctor for notification. RN C indicated LPN D did not indicate that these two events were for the same resident. RN C indicated if LPN D would have told her he was unable to get a hold of the doctor or NP, RN C would have called the doctor herself. RN C also stated it is not routine for the house coordinator-shift supervisor to assess residents in the nursing home. RN C indicated she would have gone over to the nursing home and assessed the resident if LPN D would have asked or if there was a sense of urgency. On [DATE] at 2:52 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated the facility has a physician on call 24 hours a day. DON B stated if there is a reason to call the physician between 5:00 PM and 8:00 AM, the facility is supposed to call triage at the hospital and there is always someone to answer the phone. Surveyor asked DON B what the facility does if someone does not answer at triage. DON B indicated the facility could call the house coordinator-shift supervisor. DON B stated she would expect the house coordinator-shift supervisor to suggest the facility utilize the RRT (Rapid Response Team-an interdisciplinary team that will respond to residents with significant changes in condition requiring immediate action) or send the resident to the emergency room. Surveyor asked DON B what a reasonable timeframe would be when the facility calls a physician and is waiting for a call back. DON B indicated the timeframe would depend on the severity of the resident's condition and she would expect staff to use nursing judgment. DON B also indicated if a resident is unstable the facility should use the RRT. Surveyor asked DON B if R1 was assessed by the doctor or NP during LPN D's shift and DON B indicated she is unaware if R1 was assessed. DON B indicated R1 would feel better then worse and appeared to feel better after interventions were implemented like the Tylenol and nebulizer. Of note, an ACLS RN is part of the Rapid Response Team. R1 presented with a respiratory change of condition on [DATE] at 12:30 AM that included weakness, abnormal lung sounds, a fever, and shortness of breath. The last RN assessment was performed at 8:46 AM that included new symptoms of wet, productive cough, decline in functional status, elevated temperature of 102 degrees, and lethargy. The first consultation of a physician with interventions was documented at 1:08 PM, 12.5 hours after R1's change in condition. As the day progressed, R1's condition continued to deteriorate. The facility failed to complete a comprehensive nursing assessment by a registered nurse and failed to consult with a physician resulting in R1 continuing to deteriorate and eventually expiring on [DATE]. The facility's failure to complete a comprehensive nursing assessment and notify the physician with a change in condition created a finding of serious harm, thus leading to an immediate jeopardy situation which began on [DATE]. The facility removed the immediate jeopardy on [DATE] by taking the following actions: The Administrator, Chief Nursing Officer of the Hospital, and Facility Medical Director outlining the steps to contact a physician 24 hours a day, 7 days a week. This became effective as of [DATE] at 7:00 PM. A physician will be available to assess patients 24 hours a day. This process has been communicated to all Hospitalists, Hospital Nurse Practitioners, Hospital RN House Supervisors, Administrator, Administrator Assistant, Director of Nursing, Assistant Director of Nursing, and the [NAME] President of Hospital Operations. All Nursing staff were contacted and immediately educated on this new process. On [DATE], all Nursing staff were contacted and immediately educated to ensure an RN assessment is completed when a resident presents with a change of condition, deterioration in their condition, and/or an immediate MD/NP consultation in needed in order to alter treatment if necessary. The Hospital Chief Nursing Officer also reeducated every RN Hospital House Supervisors immediately to implement the following: Frequent rounding is required in the facility to check on staff and ensure patient safety. If anyone from the facility calls the Nursing Services Office and has questions, are worried about patient safety, or seems that they are unsure what to do they are to immediately go to the facility and assess the situation and assist with calling physicians as needed. When RN House Supervisors are here, they are in charge of the hospital and everyone in it including patients and staff. The Hospitalist Physician assigned to the orange phone will respond to all calls from 7a-7p and the Hospitalist Physician assigned to the black phone will respond to all calls from 7p-7a. On [DATE] the facility Protocol for Condition Changes was revised to include the following; If a significant change in the resident's physical or mental condition occurs, a head-to-toe assessment of the resident's condition will be conducted by the RN on duty or by the MD/NP on call. The Director of Nursing has educated all Nursing Staff to the revision. On [DATE], a SNF Change of Condition Notification Protocol was developed to outline the new process of notifying the Physician of any change in a patient's condition as followed. 1. The RN Hospital Shift Supervisors will provide frequent rounding at the facility on all shifts and check in with RN/LPN on shift. 2. RN Hospital Shift Supervisors will provide assistance with any patient at the facility and will come to the unit if the facility Nursing needs immediate assistance. 3. If an LPN is on duty when the DON and/or ADON are not on duty, the RN Hospital Shift Supervisor will be contacted to conduct and document an RN assessment of the patient if there has been a change of condition or if the patient needs immediate assistance. 4. If the facility nurse is unable to reach a physician using the protocol below; the nurse will contact the RN Hospital Shift Supervisor. Physician call tree: o 7a-7p Day Orange Phone [PHONE NUMBER] o 7p-7a Night Black Phone [PHONE NUMBER] 5. If the nurse is unable to reach a physician using the call tree outlined in this protocol, the nurse is to contact the RN Hospital Shift Supervisor back who will then contact the Hospital Chief Nursing Officer for support. 6. RRTs and Code Blues called within the facility will follow the RRT or Code Blue protocols located in the Emergency Management Binder. On [DATE], a SNF Change of Condition Reporting Protocol was revised to include the following. Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. Procedure: 1. The Nurse will notify the resident's attending physician when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. b. There is a significant change in the resident's physical, mental or psychosocial status. c. There is a need to alter the resident's treatment significantly. d. The resident repeatedly refuses treatment or medications. e. The resident is discharged without proper medical authority; and/or f. Deems necessary or appropriate in the best interest of the resident. 2. The nurse will notify the resident's representative when: a. The resident is involved in any injury including injuries of an unknown source. b. There is a significant change in the resident's physical, mental or psychosocial status. c. There is a need to alter the resident's room assignment. d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital. 3. Regardless of the resident's mental or physical condition, nursing services will inform residents of any changes in their medical care or nursing treatments. 4. The nurse supervisor will record in the resident's medical record any chances in the resident's medical condition or status. 5. If a significant change in the resident's physical or mental condition occurs, a head-to-toe assessment of the resident's condition will be conducted by the RN on duty or by the MD/NP on call. 6. A representative of administration will verify the address and telephone number of the resident's representative. The Director of Nursing will audit all charts daily for any Change of Condition to ensure an RN, or MD/NP Assessment was completed. This will occur daily for 2 weeks, then weekly for 8 weeks and then monthly for 3 months. The Quality Assurance Performance Improvement Committee will review these audits monthly to ensure compliance. If an occurrence with a change of condition is identified during audits. The Director of Nursing will meet with the Nurses to identify the Root Cause of the occurrence and put appropriate measures in place for that specific occurrence for the next 4 weeks to ensure compliance. On [DATE], the Quality Assurance Performance Improvement Committee will meet to discuss the event and corrective measures to ensure compliance. The Facility Assessment has been updated on [DATE] to include RN Hospital Supervisors as a facility resource. The Facility Assessment has also been updated to reflect the training topic of Identification of patient/resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life.