**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 3 residents identified in closed records review (R31). R31 presented with a change in condition (COC) on [DATE]. Facility staff did not document all R31's symptoms in R31's medical record and did not complete a thorough and ongoing RN (Registered Nurse) assessment related to the COC. R31's condition continued to decline. R31's vital signs warranted immediate MD (Medical Doctor) notification/consultation and the facility did not notify the MD. R31 continued to deteriorate and was sent to the hospital where R31 became pulseless and nonbreathing (PNB) and expired due to a critical potassium level. The facility's failure to provide care consistent with standards of practice for R31 by not documenting signs and symptoms of a change of condition in R31's medical record, not completing an RN assessment with a change of condition, not providing continued monitoring with a known change in condition, and not notifying the Physician of vital signs timely created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on [DATE] at 12:30 PM. The immediate jeopardy was removed and corrected on [DATE] when the facility began to implement its action plan. Evidenced by: The facility's policy titled Change in Condition, undated, includes: What is considered a change in condition? The definition of a change in condition is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death . Facility staff should be able to promptly identify changes that may indicate a change in health status. Once identified staff should demonstrate effective actions to address a change in condition . an RN (Registered Nurse) who is informed of a change in condition . conduct an in-depth assessment, and then call the attending practitioner . Licensed nurses: Immediately upon notification of a change in condition, no matter how minor you feel the change may be, an in-depth evaluation must be performed on the resident. The evaluation should include a physical assessment of the resident with special focus on body systems associated with the change in condition, a full set of vital signs (including blood sugar for diabetics), a review of the resident's diagnoses list/past vitals/weights/ and medications, and a review of nurse notes for the last week to see if the change has already been noted and addressed. 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 . Interventions to Reduce Acute Care Transfers (INTERACT) standard of practice for notice of change, indicates immediate notification to the Physician if Systolic Blood pressure (BP) > 210 mmHg, < 90 mmHg; Diastolic BP >115 mmHg; Resting pulse > 130 bpm, < 55 bpm, or >110 bpm and patient has dyspnea or palpitations. American Medical Directors Association (AMDA) Acute Change of Condition (ACOC) in the long-term care setting guidelines indicate the following: an acute change of condition (ACOC) is a sudden, clinically important deviation from a patients baseline in physical, cognitive, behavioral or functional domains. Clinically important, means a deviation that, without intervention, may result in complications or death.Blood pressure, as soon as possible after admission, establish the patients usual blood pressure (BP) range. (Normal range is approximately 100 -140mmhg (millimeters of mercury) diastolic 60-90 mmHg. A change in BP is more often a symptom than a cause of an ACOC (acute change of condition) isolated BP elevations generally are not significant. Sustained elevation in systolic pressure should trigger further assessment. A BP change alone should not trigger a call to the practitioner without additional signs or symptoms (e.g., sustained elevation, new neurological symptoms.) . R31 admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, morbid obesity, polyneuropathy (nerve disorder that affects many nerves), hypotension (low blood pressure), Chronic Obstructive Pulmonary Disease (COPD; lung condition that causes breathing difficulty), and sleep apnea (sleep disorder where breathing stops). R31's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] indicates R31 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. R31's MDS also indicates R31 requires staff assistance to meet his needs in toileting, showering, dressing, transferring, going from lying to sitting or sitting to lying, and rolling side to side. R31's Comprehensive Care Plan, initiated [DATE], indicates R31 transfers with two staff assisting and with a Hoyer lift. R31's Medical Record includes the following: Nurse Note and Medication Administration Record (MAR), dated [DATE] at 2:43 AM, includes simethicone given for Gi upset. (It is important to note the facility did not perform a thorough RN assessment at this time, including an abdominal assessment such as listening for bowel sounds, palpating R31's abdomen, or collecting a full set of vitals.) R31's MAR for February 2025, includes: [DATE] at 4:46 AM Simethicone given . Nurse Note, dated [DATE] at 5:00 AM, includes: Approximately 3:00 AM resident stated, I just want to take a knife to my stomach to release the gas. This was after writer had given him simethicone due to resident request for feeling gassy. Will continue to monitor. Physician Communication Form, undated, includes: Nausea - no appetite. Severe pain. Possible appendicitis? Request - Please see R31. He is in severe pain on right side . Medical Doctor Signature - (blank) (It is important to note the facility did not perform an RN assessment at this time including palpating R31's abdomen, listening for bowel sounds, collecting a full set of vitals, or evaluating R31's pain level.) R31's MAR for February 2025 includes, [DATE] at 7:45 AM Calcium Carbonate given. Nurse Note, dated [DATE] at 9:50 AM, indicates R31 has improved but still symptomatic. (It is important to note this note does not specify what symptoms R31 was experiencing and no RN assessment is documented.) Lab Report, dated [DATE], includes: Metabolic Panel: collected- [DATE] at 11:48 AM, received- [DATE] at 12:53 PM, verified [DATE] at 1:22 PM . Potassium- 5.9 mEq/L . High (normal range reference- 3.5-4.9) . Carbon Dioxide- 21 mEq/L . low (normal range reference-23-31) . BUN-39 mg/dL . High (normal range reference-6-21) . Creatinine- 1.51 mg/dL .High (normal range reference- 0.64-1.27) . BUN/Creatinine Ratio- 26 High (normal range reference- 12-20) . (Of note: Hyperkalemia (high potassium) signs and symptoms include abdominal pain, diarrhea, nausea, and vomiting.) Physician Communication Form, dated [DATE], includes: Time - (blank) . Situation- Potassium Chloride increase to 60 mEq in morning and 40 mEq in evening on [DATE]. Was on 40 mEq two times a day prior. Held Potassium Chloride on [DATE] evening and [DATE] morning per Medical Doctor. Rechecking BMP on [DATE] . Signed by Medical Doctor on [DATE]. Nurse Note, dated [DATE] at 1:45 PM, lab results showed high potassium, MD notified and gave orders to hold potassium supplement . Physician Communication Form, dated [DATE], includes: time-(Blank) . Abdominal series (x-ray) related to abdominal pain, distension, and hypoactive bowel sounds. Portable due to impaired mobility. Hold Potassium on [DATE] and [DATE] morning. Recheck BMP on [DATE]. Signed by Medical Doctor on [DATE]. Nurse Note, dated [DATE] at 1:58 PM includes: refused noon med pass due to not feeling well. Lab Report, dated [DATE], signed at 7:15 PM includes: Reason- abdominal pain, distention, hypoactive bowel sounds . Procedure- abdomen 2 views . Findings- There are multiple prominent air-filled loops of bowel throughout the abdomen and pelvis . Impressions- Prominent loops of air filled bowel throughout the abdomen and pelvis suggestive of ileus or constipation. Distal large bowel obstruction cannot be excluded. Consider CT if needed. Physician Communication Form, dated [DATE], includes: Time - (blank) . Situation - radiology results . Request - Please find attached abdominal radiology results for review . Signed by Medical Doctor on [DATE] . R31's MAR for February 2025, includes: [DATE] at 8:50 PM Ipratropium-Albuterol nebulizer treatment performed. Nurse Note, dated [DATE] at 10:05 PM, Ultrasound results came back positive for prominent loops of air filled bowel throughout abdomen and pelvis suggestive of ileus. Awaiting further instructions from MD. (It is important to note there was only an abdominal x-ray ordered and the mention of an ultrasound may be referring to the x-ray.) R31's MAR for February 2025 includes: [DATE] at 1:17 AM Ipratropium- Albuterol nebulizer treatment performed. Nurse Note, dated [DATE] at 2:43 AM, includes: New or sudden onset/change in condition: Lethargy and change in cognition . Writer observed resident with audible tracheal congestion at 8:50 PM after requesting a (nebulizer treatment) . at about 1:00 AM writer went to check on resident status and found him lethargic, clammy and mumbling words writer could not understand . pulse and oxygen saturation could not be read as fingers were cold and clammy. Blood sugar reading was 110. Several attempts were taken to obtain vitals and later read blood pressure of 145/123 right arm, 159/109 left arm . oxygen saturation at 81%, heart rate 107 . A second (nebulizer treatment) was administered for congestion and shortness of breath as well as scheduled percocet for pain. Sliding sheet was removed from underneath the resident as it was noticed to be soaked with sweat. CPAP was applied as resident had taken it off earlier. Oxygen saturation was up to 92%. Tracheal congestion reduced and resident was able to get aroused with verbal and tactile stimuli. Brief was changed and blood smear was noted on the wipes with anal pain. At 2:43 AM resident is no longer clammy or sweating and sleeping comfortably with notable chest rise and no congestion noted. Will continue to observe. (It is important to note these blood pressure readings are critically high and this nurse did not recheck them, did not call the doctor to notify on R31's vitals or R31's change in condition, and did not perform a thorough RN assessment.) R31's MAR for February 2025 includes: [DATE] at 4:46 AM Simethicone was given. R31's MAR for February 2025 includes: [DATE] at 4:58 AM Oxycodone was given. EMS Report, dated [DATE], includes: unit notified at 5:29 AM, arrived at 6:23 AM . Narrative- Emergency Services (EMS) and First Responders paged to facility for male who was in and out of consciousness but breathing. When EMS arrived on scene charge nurse stated she believed she witnessed some seizure activity, his oxygen saturation was up and down and intermittent consciousness. They had placed him on oxygen mask at 2 liters per minute prior to EMS arrival. Patient found in bed pale and cool/diaphoretic 2 touch. Gazes straight ahead with eyes, pupils 5 to 6mm (millimeters). Does blink when hand is close to face, retracts to pain but otherwise nonverbal at this time. Nursing home staff stated that abdomen especially extended ever since beginning of shift. Due to weight, Hoyer machine used to place patient on stretcher. Once inside of ambulance vital signs obtained. During transport, oxygen saturation fluctuates up and down, those circulation appears to be poor, fingers and ears cold to touch. Patient does not answer questions, makes inaudible noises occasionally but does not communicate. Due to size of patient at one point in transport, writer had to free arm for vitals and unbuckle one strap to gain access to arm. Patient then partially on writers lab and if writer would have moved, potential for falling off stretcher. Breathing rates and pulses varied throughout transport. When writer called in report to hospital, all above observations were relayed to ER (Emergency Room) staff. ER staff questioned why vitals were so all over the place and writer stated she was unaware of why this was. When pulling into garage for ER/hospital, it was noted resident started to decline. Wheeled quickly into ER, and agonal breathing started. Once on hospital bed CPR was begun by staff . chief complaint - patient nonverbal. Nursing homes states in and out of consciousness, believe some seizure like activity . dispatched two nursing home for . male . complaining of altered mental status . [DATE] at 6:08 AM Blood pressure - 76/22 right arm . opens eyes to painful stimulation . inconsistently consolable, moaning . (It is important to note the facility provided no evidence they reported to EMS the symptoms that R31 was experiencing throughout the last 24 hours including high blood pressure readings, nausea, gas pain, extended and firm abdomen, tracheal congestion, or shortness of breath. It is also important to note the facility did not provide evidence of reporting R31's received lab results being positive for prominent loops of air filled bowel throughout abdomen and pelvis suggestive of ileus or constipation . distal large bowel obstruction cannot be excluded . and the EMS Report does not capture this information in R31's history or chief complaint.) emergency room Intake Note, dated [DATE], includes: date and time of service- [DATE] at 5:42 AM . Patient coming from facility. Staff called and stated that last night patient began having labored breathing. States she gave nebulizer and patient seemed to improve. States that as the night progressed he became more restless and short of breath. States oxygen saturations were in 70's. Staff gave another nebulizer and put patient on 2 liters of oxygen per minute via nasal canula. States started to become agitated and complaining of abdominal pain. Staff gave pain medication with no relief. Patient had abdomen ultrasound yesterday suggestive of an ileus. Staff stated patient abdomen is much more distended than normal. Patient is a hoyer lift. emergency room Note, dated [DATE], includes: date and time of service- [DATE] at 6:22 AM . Patient is a . male with history of hypertension (high blood pressure), hyperlipidemia (high level of fats in the blood) , type 2 Diabetes Mellitus, chronic obstructive pulmonary disease, obstructive sleep apnea, . presenting EMS for hypoxia and found to be pulseless and nonbreathing . Patient comes from facility where staff report he began having labored breathing last night that seemed to improve with a nebulizer treatment. States he became more short of breath and restless throughout the night with oxygen saturations in the 70s. Staff then gave another nebulizer treatment and put him on 2 liters of oxygen. He subsequently became agitated and complained of abdominal pain that was not improved with pain medication (ultrasound was done suggestive of ileus yesterday), and EMS was called. Patient continued to decompensate en route per EMS and became unresponsive with fixed gaze. As patient was wheeled into our Emergency Department, I noted the patient to be apneic and he did not have a pulse. So I started CPR (Cardiopulmonary Resuscitation) and CODE HEART was called . I was the one who discovered the patient to be in cardiac arrest. I started chest compressions myself and called a CODE HEART. Patient was difficult to bag and due to not having enough staff present for safe intubation, I inserted a #5 IGEL and patient was bagged until respiratory therapist was available to assist while continuous chest compressions were ongoing. Patient was too large . and so continuous high quality CPR was carried out throughout the code. Patient did not have IV access, IV was very difficult to obtain and so I placed the left tibial IO (intraosseous (injecting Intravenous medications directly into the bone marrow)), original IO attempt on the right was unsuccessful. Patience rhythm was PEA ((pulseless electrical activity) a form of cardiac arrest where the heart shows electrical activity but does not provide a pulse) throughout the arrest. He was noted to be [NAME] cardiac wide complex PEA. Patient ended up receiving 3 A of sodium bicarbonate, 2 A calcium chloride and a gram of magnesium . in addition to 7 mg of epinephrine throughout the code. Utilization of bedside ultrasound showed cardiac contractility midway through the code and ROSC (return of spontaneous circulation, which is the return of a pulse and blood pressure) was achieved but patient subsequently [NAME] cardiac down and had subsequent cardiac arrest shortly thereafter prompting repeat CPR and more rounds of epinephrine. We attempted pacing with some capture for a brief period however patients cardiac contractility was not sufficient enough to sustain life as so pacing was stopped and CPR was continued. VBG (Venous blood gas) noted potassium of 7.1 with very low pH . unclear whether this was a hemolyzed sample or not but given the [NAME] cardiac PEA with wide complex, my suspicion was true hyperkalemia and we treated with multiple amps of bicarbonate/calcium and magnesium . Labs were obtained showing hyperkalemia and very high white blood cell count. Given recent history of ileus, this may be severe dehydration leading to AKI (acute kidney injury) with hyperkalemia and/or sepsis however despite resuscitation, patient was without a pulse a prolonged period of time in our ED. It was deemed medically futile to attempt continued resuscitation and therefore the patient was pronounced deceased at 7:06 AM. He did not have a pulse, was not breathing. His final rhythm was bradycardiac PEA rate of 22 (agonal) . Timestamps: 6:26 AM manual compressions began . 6:27 AM code heart called overhead . 6:31 AM 1 mg epi given . 6:31 AM pause, pulse check-PEA on monitor, compressions resumed . 6:34 AM 1 mg epi given . 6:35 AM intubated . 6:36 AM pause, pulse check- PEA on monitor, compressions resumed . 6:37 AM sodium bicarb given . 6:38 AM 1 mg epi given . 6:41 AM 1 mg epi given . 6:42 AM pause, pulse check- PEA on monitor, compressions resume . 6:44 AM 1 mg epi given . 6:46 AM pause, pulse check via bedside ultrasound- ROSC obtained . 6:49 AM sodium bicarb given . 6:50 AM 1 g calcium chloride given . 6:52 AM 1 mg epi given . 6:55 AM pause, pulse check via bedside ultrasound- cardiac activity, bradycardiac, compressions resumed . 6:56 AM 1 g calcium chloride given . 6:57 AM sodium bicarb given . 6:58 AM pause, pulse check- bradycardiac agonal, compressions resumed . 7:00 AM 1 g magnesium sulfate given . 7:01 AM 1 mg epi given . 7:02 AM pause, pulse check- agonal PEA wide complex. Compressions resumed . 7:05 AM pause, pulse check- final rhythm: bradycardia PEA, agonal wide complex . 7:06 AM time of death . Diagnoses: Cardiac arrest, hyperkalemia . Nurse Note, dated [DATE] at 6:48 AM, includes: Resident was banging his hands on the wall at about 4:00 AM and was calling out Help multiple times. When writer and CNAs (Certified Nursing Assistants) arrived at his room he continued to call out for help and was incoherent. He took off his CPAP and could only answer to his name. Resident's abdomen was distended and tender on palpation and he complained of pain in his shoulders and neck. Simethicone and oxycodone was administered. Oxygen saturation dropped to 71%, 2 Liters oxygen was applied via nasal canula. 911 was then called and DON (Director of Nursing) notified. Oxygen saturation rose to 88% after oxygen was administered. EMS (Emergency Services) left with resident at 6:10 AM . Facility Timeline indicated in their action plan, dated [DATE], includes: On [DATE] at 11:00 AM CNA (Certified Nursing Assistant) attended to R31 to give him a bed bath. CNA noted that resident exclaimed in pain when she attempted to wash resident's lower right stomach area. Due to this pain, CNA opted not to wash resident's back until nurse was available for skin check so as to only roll resident once in bed. At this interaction R31 also refused lunch due to stomach pain. CNA noted this to be unusual for R31 and reported both pain and lunch refusal to nurse. (It is important to note R31's Medical Record did not contain this information. This information was collected after R31 passed (on [DATE]) while the QAPI team investigated and started a plan of correction related to R31's care.) Nurse Note, dated [DATE] at 9:15 AM, includes: Late entry for [DATE] . Writer notified of resident's complaints of abdominal pain/nausea and refusal of breakfast and lunch. Writer in to assess resident at 1:00 PM . resident verbalized generalized discomfort in abdomen. Writer auscultated bowel sounds and bowel sounds were noted to be hypoactive in all quadrants . Resident reported pain with palpation of right upper quadrant where old scar tissue is, as well as acute pain with palpation in left lower quadrant. Abdomen distended and more firm than usual for resident. Doctor updated and order for abdominal X-rays obtained. Writer also received resident's BMP (Basic metabolic panel) results at that time, and potassium was noted to be elevated at 5.9, and kidney function markedly decreased from previous labs. Doctor updated on lab results and orders received to hold potassium on [DATE] PM (med pass) and [DATE] PM (med pass), recheck BMP on [DATE], and that doctor would be in to see resident on the morning of [DATE]. Resident updated with plan and in agreement. [company name] in and X-ray completed. Results were received later in the day and showed constipation or ileus, or large bowel obstruction. Resident had change in condition overnight including restlessness vital signs all over the place . and requesting resident transfer to hospital. Writer was in agreement and resident was transferred out [DATE] early morning. Writer received notice shortly after that resident had coated and expired in the hospital. Administrator and doctor made aware. (It is important to note R31's medical record did not contain this RN assessment ([DATE] at 1:00 PM) until after his passing when a late entry was added.) Nurse Note, dated [DATE] at 9:21 AM, includes: resident was not feeling well, had bloated abdomen, pain, and nausea. Resident refused breakfast and lunch. Abdominal x-ray series ordered and performed. Resident slept on and off most of the day . On [DATE] at 4:24 PM during interview with Surveyor, ADON P (Assistant Director of Nursing) indicated a full set of vitals includes a temperature reading, pulse reading, oxygen level reading, blood pressure reading, blood sugar reading if resident is diabetic, and respiration reading. ADON P indicated an abdominal assessment should include palpating for pain and firmness, listening for bowel sounds, and a full set of vitals. ADON P indicated if a resident reports pain, the nurse should ask location of pain and intensity using the pain scale 0 to 10. ADON P indicated it is important to document findings in resident's medical record. On [DATE] at 5:17 PM during interview with Surveyor, DON B (Director of Nursing) indicated when R31 reported abdominal pain she expected the nurse to gather information about this including where the pain was located, what the intensity of the pain was, and DON B indicated she expects the nurse to record her findings in R31's medical record. DON B indicated a thorough abdominal assessment would include palpating for pain, listening to the four quadrants for bowel sounds, a full set of vitals, and a blood sugar check. DON B indicated a pain assessment would include gathering information related to where the pain is located and a pain rating. DON B indicated when R31 stated he just wanted to take a knife to his stomach to release the gas, she expected the nurse to perform an abdominal assessment and a pain assessment but this did not occur. DON B indicated the nurse that was working was let go and is no longer employed by the facility. DON B indicated she performed an RN assessment on [DATE] at 1:00 PM, but the nurse on the floor never documented this in R31's medical record and should have. DON B indicated all signs and symptoms of a change in condition should be captured in a resident's medical record, including missed or refused medications, missed or refused meals, nausea, seizure activity, firmness in abdomen, bloating, pain, abdominal distension, abnormal lab values, shortness of breath, congestion, and more. DON B indicated a blood pressure reading of 145/123 or 159/109 would be alarming and she would expect the nurse to recheck the blood pressure and if it has not changed, notify the MD. DON B indicated upon notice of R31's death the facility called together an emergency QAPI (Quality Assurance Performance Improvement) meeting where they identified deficient practice and began to put together a plan of correction. On [DATE] at 11:37 AM during interview with Surveyor, RN Q indicated she was the nurse on the floor when R31 said I just want to take a knife to my stomach to release the gas. RN Q stated she gave R31 another one of his simethicone for gas and bloating. RN Q stated, I noticed he was bloated. It was not hard. Could tell he was uncomfortable and this was not his normal. I palpated and felt he was distended and gassy, but not hard. RN Q indicated she did not remember if she took R31's vitals at this time. RN Q indicated she did notify R31's MD about a hard mass that was found on [DATE] and she did not think to notify his MD about his abdominal pain as she assumed it was all related. When asked, RN Q stated, I did not perform a full RN assessment. I received education on change in condition since this incident. I should have done an assessment and called MD N. On [DATE] at 12:23 PM during interview with Surveyor, LPN R (Licensed Practical Nurse) indicated she no longer works for the facility and she does not remember this resident. On [DATE] at 12:36 PM during interview with Surveyor, MD N (Medical Doctor/Medical Director) indicated the facility identified some concerns when they performed a look back at R31's last 48 hours, including the nurse on the floor did not perform thorough assessments until DON B performed one on [DATE], but even then it was not recorded in R31's medical record. MD N indicated the facility did not perform ongoing close monitoring as she would have expected. MD N indicated the facility did not notify her of R31's change in condition every time he developed new symptoms. MD N indicated if the facility had notified her sooner, R31 may have been sent out to the emergency room sooner, but she did not believe the outcome would have changed. MD N indicates she expects the facility to document signs and symptoms of a change in condition in R31's medical record, including missed/refused meals, missed or refused medications, pain, abdominal bloating, nausea, abdominal distention, firmness of the abdomen, seizure activity, and more. MD N indicated a full set of vitals includes a temperature. MD N indicated the facility realized they were out of compliance and began to make a plan of correction immediately. MD N indicated if a resident states he wants to take a knife to his stomach to release the gas, her expectation is the staff would perform a pain assessment to gather pain level/location/intensity and an abdominal assessment that includes palpating for pain/tenderness/firmness, listening for bowel sounds, a full set of vitals. On [DATE] at 1:07 PM during interview with Surveyor, NP O (Nurse Practitioner) indicated the week of [DATE] she was out of work status and did not take any calls regarding R31. NP O indicated when a resident presents reporting pain in the abdomen it is her expectation that the facility will perform an RN assessment, including a full set of vitals, bowel sounds, palpating the abdomen for distention and/or firmness. NP O also indicated the facility should call her or the MD with the gathered information. NP O indicated a blood pressure of 145/123 and 159/109 could be critical especially associated with other symptoms. NP O indicated it is her expectations that staff would document all signs and symptoms of a change in condition in the resident's medical record, including missed/refused medications, missed or refused meals, nausea, pain, seizure activity, mental status changes, distention, bloating, and more. NP O indicated R31 could have been sent out to the emergency room sooner and maybe the outcome could have changed, but maybe it wouldn't have because NP O stated R31 was a very unwell man. The facility's failure to assess R31 when he was experiencing a significant change in condition and failure to take appropriate action in response to the change in condition, such as documenting signs and symptoms, consulting with a physician, and providing continued monitoring created a reasonable likelihood that serious harm or death could occur and led to a finding of immediate jeopardy. The Immediate Jeopardy was removed and corrected on [DATE] when the facility completed the following: - LPN R's employment was terminated. - Vitals were taken on all residents to ensure no change in condition/need for additional assessment - Educational in-services on change in condition were provided for all clinical staff to be completed by the end of their shift for those present and prior to starting next shift for those not present - Interviewed all residents and [NAME] of Attorney regarding comfort with cares, facility responsiveness to clinical needs to ensure the facility continues to meet the resident needs to their satisfaction - DON B performed 72 hour chart review for all residents to ensure all changes in condition noted were accompanied by follow-up assessments and proper notification. - DON B organized a skills fair for nursing to ensure competence in assessments, evaluations, nursing skills, and clinical judgement - Management team revamped morning[TRUNCATED]