**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition post procedure. This occurred for 1 of 4 residents (R15) reviewed for physician notification and consultation. R15 presented with new symptoms of lethargy and fever post ureteral stent placement. Staff did not immediately notify R15's provider of this occurrence resulting in actual harm when R15 was found unresponsive and admitted to the hospital 12/07/23 - 12/13/23, with a diagnosis of sepsis (a serious condition in which the body responds improperly to an infection) secondary to acute (sudden onset) pyelonephritis (a type of urinary tract infection where one or both kidneys become infected), acute hypoxic respiratory failure (happens when you don't have enough oxygen in your blood), and acute metabolic encephalopathy (caused by a chemical imbalance in the blood. The imbalance is caused by an illness or organs that are not working as well as they should). Findings include: The facility policy entitled, Change in a Resident's Condition or Status, dated 6/17/19, states: .Our facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition .The nurse will notify the resident's attending Physician or on-call Physician when there has been: .a significant change in the resident's physical/emotional/mental condition; instructions to notify the Physician of changes in the resident's condition .A significant change of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; .ultimately is based on the judgment of the clinical staff and the guidelines outlined in the resident assessment instrument and 42 CFR 483.20(b)(ii) . Monitoring Protocol Post Procedure includes: After readmission to the facility postoperatively, the physician and staff will maintain appropriate communication with the referring surgeon to ensure that the resident receives adequate postoperative care and that the staff and attending physician receive relevant medical information . The staff and physician will monitor for and address postoperative risks and complications such as infection, deep vein thrombosis, cardiac arrhythmia, bleeding, failure of surgical wounds to heal, urosepsis from indwelling catheters inserted in the hospital, delirium, depression, etcetera. R15 was admitted to the facility on [DATE], and had diagnoses that included in part, dementia, epilepsy, diabetes, urinary tract infection, and kidney stones. R15 had a ureteral stent placed on 12/05/23 as an outpatient procedure and returned to the facility the same day. On 12/07/23, R15 was sent from the facility to the hospital and admitted with diagnoses of sepsis secondary to left acute pyelonephritis, acute hypoxic respiratory failure, and acute metabolic encephalopathy. R15 returned to the facility on [DATE]. R15's care plan, dated 12/20/23, states: .The resident has a history of Urinary Tract Infection (UTI), sepsis due to pseudomonas bacteremia with left sided pyelonephritis, recurrent kidney stones, recurrent cystitis. Interventions include: The resident's urinary tract infection will resolve without complications by the review date. Encourage adequate fluid intake. Give antipyretics, analgesics, and antispasmodics as ordered/PRN (as needed). Monitor/document for side effects and effectiveness. Monitor/document/report to MD (Medical Doctor) PRN for signs or symptoms of UTI: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . R15's care plan, dated 10/15/22, states: .The resident has chronic mixed bladder incontinence related to loss of peritoneal tone, use of antidepressant, antianxiety, and antipsychotic medications, diabetes, weakness, chronic dysuria, kidney stone lithotripsy, and JJ stent placement 12/5/23 urinary retention, UTI history. Interventions include: [R15] will often refuse to ambulate to bathroom but will inform staff of when her incontinence product needs to be changed. Clean peri-area with each incontinence episode. R15's orders: Nitrofurantoin Macrocrystal Oral Capsule 100 MG (Nitrofurantoin Macrocrystal) Give 100 mg by mouth two times a day for urinary tract infection for 7 Days. Start 11/30/2023. End 12/7/2023. This antibiotic was prescribed prior to R15's ureteral stent placement and continued through until the hospital admission on [DATE]. R15's urine culture collected 11/28/23 indicated Escherichia Coli. R15's urine culture collected during the hospitalization on 12/07/23 indicated Pseudomonas Aeruginosa. Prior to stent placement: 11/22/2023 Resident had a preop visit today. Okay to proceed to surgery. Medically optimized. Procedure is 12/05/23. Prior to the procedure, R15 was clinically cleared to have the ureteral stents procedure completed. Prior to the ureteral stent procedure, R15 had no difficulty with lethargy, fevers, nausea/vomiting, hypoxia, or mentation. Post stent placement: R15's nursing note on 12/5/2023 at 12:43 PM: Resident returned from procedure for ureteral stent placement at 12:45 PM. R15's after visit summary for ureteral stent placement dated 12/05/23: .Seek emergency treatment if you experience: inability to urinate, chest pain, shortness of breath. Call your provider if you experience: Temperature greater than 100.4, pain not relieved by medication, wound swelling/bleeding/redness, foul smelling/pus-like drainage, persistent dizziness or light headedness, urine is ketchup colored or you have large clots, opening of the stitches or wound edges even after sutures have been removed, rash, calf pain redness or firmness in your leg, heavy bleeding, nausea/vomiting . R15's nursing note on 12/6/2023 at 11:01 AM (late entry): Resident very lethargic at 8:00 AM, needed assist with taking of medications, spoon fed and then handed glass of water x 2, this writer stayed in room while resident took medications, temperature at 9:15 AM 101.2 room heat on very warm in room and resident covered with numerous blankets, resident received scheduled APAP (Tylenol) at 8:30 AM, pulse 100, respiratory rate 16, oxygen sats 90% on room air non labored and regular breaths, blood pressure 137/68 skin warm, dry and flushed, rechecked temp at 9:40 AM 100.1, rechecked temp at 10:30 AM 100.9 rechecked temp at 11:00 AM 100.4 resident responding to name and making eye contact, encouraged to drink fluids, skin warm dry and pink. *Note: R15 was post ureteral stent placement on 12/5/23 and became very lethargic with a temperature of 101.2 despite Tylenol given 45 minutes earlier. Post procedure orders were to call the provider for a temperature greater than 100.4. The facility failed to call the provider to notify of these signs and symptoms. R15's nursing note on 12/6/2023 at 6:12 PM (late entry): At 3:30 PM, resident's temp was 98.0. She was shaking and stated she was having pain. PRN Tylenol was administered. At 4:00 PM, resident had emesis x 3 followed by dry heaving. Vitals at 4:00PM: Temp 98.0, BP 148/82, HR 121, RR 18, O2 92. Doctor on call was notified. Order a change to tramadol from 50mg Q4H to 25mg Q6H with same end date of 12/08. Also ordered Zofran 4mg ODT Q8H for nausea/vomiting. At 5:00 PM vitals were: Temp 97.7, BP 142/76, HR 122, RR 18, O2 92. Resident appearing more alert and shaking ceased. Drinking water but no hunger for food at this time. R15's vital signs on 12/06/23 at 8:10 PM: Oxygen saturation 94% room air, blood pressure 138/72, pulse 124 beats per minute / regular, respiratory rate 16 breaths/minute, temperature 98.1 degrees Fahrenheit. R15's nursing note on 12/6/2023 at 9:03 PM (late entry): At 8:30 PM VS (vital sign) stable, except HR (heart rate) was 124. Resident states she is feeling better and did take her HS (hour of sleep) meds. She is encouraged to drink fluids and notify staff if she is feeling nauseated or unwell. *Note: Pulse of 124 is abnormal. Normal range 60-100. The facility did not notify the provider that there was no improvement as the pulse was still elevated at 124 beats per minute four hours after notification was made to the provider at 4:00 PM earlier that day of elevated pulse and emesis. R15's nursing note on 12/7/2023 at 12:54 AM: Resident developed a temperature of 100.9. She is two days post ureteral stent placement. She has a change in cognition/mentation, unable to answer questions, unresponsive to stimulus. She can answer what her name is, but not where she is or anything else. VSS (vital signs stable) updated in PCC (point click care). POAHC (power of attorney health care) contacted and in agreement with sending to ER (emergency room) for evaluation. On call provider contacted, he is in agreement with sending to ER. DON (director of nursing) notified of transfer. Forms completed. Call to ER for report on incoming transfer. R15's vital signs on 12/07/23 at 1:04 AM: Oxygen saturation 87% room air, blood pressure 148/88, pulse 128 beats per minute / regular, respiratory rate 18 breaths/minute, temperature 100.9 degrees Fahrenheit, repeat temperature at 1:05 AM 102.6 degrees Fahrenheit. R15's history and physical hospital note dated 12/07/23: She recently underwent ureteroscopy and JJ ureteral stent placement on 12/05/23. She was taken to the emergency department as she was noted to have altered mental status and had developed fever. She also had two episodes of vomiting. On presentation she was tachycardic with heart rate in the 110s and hypoxic with oxygen saturation 89 percent on room air, improved to 95% on 2 liters nasal cannula oxygen. Her labs were significant for Leukocytosis with WBC (white blood cell) 23.3 (neutrophilic predominance), elevated anion gap of 16, elevated lactate of 4.4. Urinalysis was positive for nitrates, leukocyte esterase, ketones, WBC greater than 100, RBC (red blood cell) greater than 100. Chest X-ray showed no acute findings and CT abdomen pelvis showed patch areas of decreased enhancement in the left kidney. Left double J nephroureteral stent in place with mild periureteral and perinephric fat stranding, suggestive of left pyelonephritis and left ureteritis; no urinary tract stones were seen. Lactate trended down to 3.6 with IV (intravenous) fluids. She received a three-liter bolus of normal saline, IV ceftriaxone 2grams, she was continued on maintenance IV normal saline at 100 milliliters an hour. Samples were collected for blood and urine cultures. She was discussed with Urology by the emergency department with recommendations for placement of a Foley catheter to expedite removal of infected urine. She was transferred to the hospital in Eau [NAME] as there were no inpatient beds available in Menomonie. R15's Discharge Summary Hospital Note dated 12/13/23: Principal diagnosis: 1) Sepsis secondary to left acute pyelonephritis and left ureteritis 2) Acute hypoxic respiratory failure 3) Acute metabolic encephalopathy R15 was discharged back to the facility on [DATE] with fever resolved and mental status returned to baseline. R15 was started on IV cefepime at the hospital and continued at the facility until 12/21/23. Interviews: On 06/20/24 at 9:50 AM, Surveyor asked Director of Nursing (DON) B what the expectation would be to notify the provider with the change in condition for R15. DON B stated the nurse should have notified the provider at that time of R15 being very lethargic and temperature of 101.2. Surveyor asked DON B for any provider notification documentation on R15 post ureteral stent placement until she was hospitalized . Surveyor asked DON B for the policy and procedure for provider notification. On 06/20/24 at 11:15 AM, Surveyor interviewed Registered Nurse (RN) E and RN F and asked what the expectation is for notification to the provider of a resident who came back from a ureteral stent procedure. Both RN E and F said if there were any abnormal things found during assessment of the resident, they would call the provider/send the resident out to the hospital/email/place on follow up board depending on how severe the findings were. Surveyor told RN E and F of R15's symptoms on 12/06/23 in the morning and asked what they would have done with this information. Both RN E and F said they would have called the provider and pushed to have the resident sent to the hospital and monitor resident closely due to being very lethargic with a temperature post procedure. On 06/20/24 at 12:35 PM, Surveyor interviewed RN G (the nurse for Medical Doctor (MD) H who placed the ureteral stents) about R15's ureteral stent placement if the facility had contacted the provider prior to R15 being hospitalized on [DATE]. RN G said there was no communication from the facility to MD H. Surveyor explained the signs and symptoms R15 was experiencing on 12/06/23: resident very lethargic at 8:00 AM, temperature at 9:15 AM 101.2 room heat on very warm in room and resident covered with numerous blankets, resident received scheduled APAP (Tylenol) at 8:30 AM, pulse 100, respiratory rate 16, oxygen sats 90% on room air non labored and regular breaths, blood pressure 137/68 skin warm, dry and flushed. Notified RN G of the rechecked temperatures. Surveyor asked RN G what the expectation is for the facility to do with this information post ureteral stent. RN G said the expectation was for the facility to call the provider once these symptoms occurred. On 06/20/24 at 1:00 PM, Surveyor asked DON B if they had found any provider notification of R15. DON B said no, they could not find any documentation. On 06/24/24 at 12:30 PM, Surveyor interviewed MD H and made aware of the facility's nurse's note on 12/06/23 that stated R15 was very lethargic at 8:00 AM, Tylenol given at 8:30 AM, and fever of 101.2 at 9:15 AM, post ureteral stent placement. Surveyor asked MD H what the expectation is for the facility to do with the information concerning R15's signs and symptoms post ureteral stent. MD H stated she would expect the facility to call her because of the temperature and lethargy, especially since R15 had received Tylenol. Surveyor asked MD H what she would have done if the facility had called her with this information. MD H said she would have sent R15 to the emergency department for further evaluation. Surveyor asked MD H if R15 was sent to the hospital upon first signs and symptoms on 12/06/23, would that have changed the hospital course. MD H said R15 was placed on Macrobid appropriately prior to the stent placement. Post stent placement urine culture at the hospital was a different strand needing a different type of antibiotic. MD H stated R15 would have likely still been hospitalized due to the infection, but if she was notified sooner of R15's symptoms and R15 sent to the hospital sooner, the severity of R15's signs and symptoms upon hospitalization could have been prevented. When R15 was hospitalized on [DATE] the symptoms of hypoxia and metabolic encephalopathy were present.