**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring emergency care and failed to immediately notify emergency medical personnel for 1 of 4 total sampled residents (R1). R1 was found pulseless and not breathing on [DATE]. R1's Physician Orders, Care Plan, CNA (Certified Nursing Assistant) Kardex, EHR (Electronic Health Record) banner, and MAR (Medication Administration Record) indicated R1 was a full code. Staff failed to immediately initiate CPR and immediately contact emergency medical personnel. Facility failure to immediately begin cardiopulmonary resuscitation and immediately summon emergency medical personnel created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 12:00 PM. The immediacy was removed and corrected on [DATE].This is evidenced by:Per CMS (Centers for Medicare and Medicaid Services) Cardiopulmonary resuscitation (CPR) refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased.Per The American Heart Association, all potential rescuers are to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer.Per CMS, when addressing full-code residents: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services.The facility's policy, Cardiopulmonary Resuscitation (CPR), reviewed [DATE], documents, in part, as follows: Licensed staff will be responsible for knowing how to access the code status of each resident if this information is needed.BLS (Basic Life Support) equipment including a cardiac arrest board, suction, oxygen and related supplies, and the AED (Automated External Defibrillator) will be stored in the Oxygen Equipment Room in the AED.In the event of discovery of cessation of breathing and/or pulse, the staff will:Call for assistance using the paging system or verbally alerting other staff on duty.Verify the resident's code status.Delegate to staff persons the tasks of obtaining the emergency equipment, calling the ambulance, and notification of the physician.If the resident's code status is a YES CPR, position the resident on a firm surface or the cardiac arrest board and initiate CPR following the BLS standards for CPR.Continue CPR until Emergency Medical Personnel arrive.R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, congestive heart failure acute on chronic (sudden worsening of chronic heart failure symptoms), coronary artery disease (damage to the heart's blood vessels), peripheral vascular disease (a circulatory condition that reduces blood flow to the limbs), diabetes mellitus type 2 (the body has trouble controlling blood sugar), and acute kidney failure (the kidneys do not efficiently filter waste from the blood).On [DATE] R1's power of attorney for health care was activated with a family member serving as her APOAHC (Activated Power of Attorney for Health Care). On [DATE], R1's POST (Provider Orders for Scope of Treatment) was completed and signed by a physician and R1's APOAHC. The POST documents: FIRST follow these orders, THEN contact physician. This is a medical order form based on the person's medical condition and preferences. Recognize the dignity of all people and treat everyone with respect.R1's POST indicates the following: Cardiopulmonary Resuscitation (CPR) - Attempt Resuscitation/CPR - If patient has no pulse and is not breathing attempt CPR.On [DATE], R1's APOAHC signed R1's POST a second time when R1's code status was revisited with R1 and R1's APOAHC. R1's POST remained Cardiopulmonary Resuscitation (CPR) - Attempt Resuscitation/CPR - If patient has no pulse and is not breathing attempt CPR.R1's Significant Change Minimum Data Set (MDS) dated [DATE] indicates R1 has a Brief interview of Mental Status (BIMS) of 9 out of 15 indicating she is moderately cognitively impaired. On [DATE], R1's Care Conference documents in part: Type: Significant Change Notes: .Resident's POST reviewed and resident/Activated HCPOA (Health Care Power of Attorney)/family continue to feel that Full Code should continue. Risks vs benefits of CPR (Cardiopulmonary Resuscitation) explained, and resident/family continue to want CPR.Surveyor reviewed R1's Full Code status is consistent in the following areas:R1's Physician Orders, signed by the physician [DATE], document R1 is a Full Code.R1's CNA Kardex has a green sticker indicating Full Code.Surveyor reviewed R1's EHR (Electronic Health Record) banner and MAR (Medication Administration Record) which both indicate R1 is a Full CodeXXX[DATE] at 4:24 AM, RN C (Registered Nurse) documented the following Progress Note: Called to resident's room by CNA (Certified Nursing Assistant), resident not breathing no heartbeat, skin cold to touch. CNA had been in at 2:00 AM with resident to check on her and she was fine. Called and updated Physician F (Physician name) on resident condition and felt no need to start CPR (Cardiopulmonary Resuscitation) due to no heartbeat and skin cold to touch. Updated family member (name) and will be in to see R1. Resident was assessed earlier this evening at bedtime and all VS (vital signs) were good and stable. Resident refused supper last night and would only take sips of liquid. On [DATE], a nurse reviewing R1's chart noted RN C's (Registered Nurse) Progress Note (above) and notified NHA A (Nursing Home Administrator). NHA A notified DON B (Director of Nursing).The facility initiated a Self-Report to the State Agency. NHA A and DON B reached out to staff working that shift: RN C , CNA D, and LPN E (Licensed Practical Nurse).The facility's Self Report documents as follows:Date occurred: [DATE]Time occurred: 4:30 AMOccurred date and time estimated: YesDate discovered: [DATE]The facility's investigation includes the following:On [DATE] R1, full code status, with a history of Peripheral vascular disease, diabetes, kidney failure, protein-calorie malnutrition, chronic congestive heart failure, prosthetic heart valve, depression. Over the last 6 months, R1 experienced a significant decline, weight loss and just an overall decline in health. Noted [DATE] a significant change occurred again on [DATE] that triggered a MDS (Minimum Data Set) change. On several occasions, social services and nurse managers went over the code status and educated them on what that would mean for R1. The choice was always to remain a full code or that they would think about changing it. Hospice was offered to the family due to the decline but was declined as well. Several attempts to address the decline, interventions were in place to help improve wound care and nutritional status. R1 was not taking in. [sic]On [DATE], RN C (Registered Nurse) was called to R1's room after CNA D called her to the room. R1 had no pulse and was cold to the touch. Per the charting CNA was in with her on the 2:00 AM rounds and noted that she was fine and still alive at that time. RN C called the physician on call, Physician F, and it was decided that due to no heartbeat and skin cold to touch, they were not to initiate CPR (Cardiopulmonary Resuscitation) Physician F instructed RN C to update her HPOA (Healthcare Power of Attorney) as to the decision. HPOA and family indicated that they were grateful of the call and the care that was provided to R1.On [DATE] at 11:51 AM, NHA A and DON B spoke with Physician F. Physician F stated that she received a call at 4:17 AM on [DATE] in regard to R1. Physician F stated, RN C, let her know that they found R1 without a pulse and cold to touch. She stated she then instructed the nurse that they should not do CPR as it would not do any good at the time. NHA A and DON B educated Physician F on the regulation and that regardless of the situation, we are required to at least start the CPR, and the determination can be made after EMS (Emergency Medical Services) has a chance to take over.On [DATE] at 1:55 PM, NHA A and DON B spoke with RN C regarding the events that occurred. I (NHA A) read off the progress note and asked if she wanted to add anything to that for her statement. RN C stated that when she was called into the room, R1's face was cold, her hands were cold and at that point she felt that there no [sic] nothing more that could be done as she would suggest it had been a while without a pulse. She stated that as soon as she was brought into the situation, she went to call Physician F right away to get guidance on the situation. RN C stated that she has [sic] a conversation with DON B a couple weeks prior to this event, letting the DON know she didn't think it was appropriate for residents to be a full code. DON B responded and reminded her that it was not the facility choice and that it was the residents' choice regarding code status and no matter what, she needed to complete code if anything occurred. DON B reminded RN C that she understood what DON B relayed to her 2 weeks ago. NHA A educated RN C, that when someone is full code that no matter how cold their body is at the time, that we are required to initiate CPR and call EMS. RN C then asked if there was a policy that would help with decision making in the building in this type of event, NHA A stated, the policy states what was discussed and there is no deviation from the residents' request. RN C has been suspended pending investigation.On [DATE] at 2:45 PM, NHA A and DON spoke with CNA D about the night as she was as she was the primary caregiver on the wing and the one that initially found R1. Per CNA D, she had done rounds with R1 at 2:00 AM, at that time R1 was alive and breathing. When she returned at 4:00 AM to complete rounds she stated that she spoke to R1 and told her that she was going to be pulling the blankets back, at that time she noticed that R1's hands were purple, and her face was cold. But overall that she didn't feel like she was cold all the way around and felt that she had some warmth to her. She stated she then went directly to the nurse (RN C) and the nurse came down. CNA D then stated she had asked what they were supposed to do, RN C then responded that she was not aware what she should do in the situation and then asked her to run get LPN E for guidance. CNA D stated that she went to get LPN E, LPN E told CNA D that they needed to start CPR and to grab the crash cart. CNA D grabbed what was asked and ran down the hallway, to which we met RN C at the time. RN C was on the phone with Physician F who instructed them not to start CPR as R1 was gone. They called the family and the funeral home at that time. NHA A and DON B explained to CNA D that we are required to start CPR no matter the situation as long as their advance directives states that they are a full code. On [DATE] at 3:48 PM, DON B spoke with R1's PCP (Primary Care Provider) regarding R1's passing over the weekend. DON B updated PCP that CPR had not been performed based on conversation that was had between RN C and Physician F. PCP stated that he was aware of R1's fragile state and agreed that CPR would have been futile. Moving forward R1's PCP indicated that he will be reviewing the code status for all residents he is presently following at the facility and will be having more detailed conversation with residents and their families, as changes in condition warrant. DON B educated PCP on State/Federal guidelines for nursing home residents, in regard to performing CPR and discussed the detailed criteria needed if CPR is not performed on someone who is a full code. PCP had no concerns with how care had been provided and response of staff and agreed with Physician F decision based on assessment provided to Physician F from RN C.On [DATE] at 1:55 PM, Surveyor spoke with LPN E (Licensed Practical Nurse) regarding the situation that occurred with R1. LPN E stated that CNA D came to her and told her that they had a code and R1 was a full code, and the nurse (RN C) was not sure what to do at the time. LPN E told CNA D to grab the crash cart, and she ran over to the wing. When LPN E arrived to the wing to assist with the code, she met with RN C stating that she was not going to perform CPR as R1 was cold. LPN E stated that she needed to begin CPR or call the Dr. That's what RN C did and was informed not to begin CPR. NHA A and DON B educated LPN E that we are required to start CPR, and that EMS needs to be called no matter what. LPN E then asked what she should do in the future since she is an LPN, and an RN stated not to do CPR. Educated LPN E that she needs to begin CPR if they are full code no matter what. On [DATE] at 2:00 PM, Surveyor asked RN C to describe the events that occurred when R1 passed away. RN C stated she had seen R1 earlier in her shift and had encouraged fluids. RN C stated R1 was not eating much. RN C took R1's vital signs and blood sugar. RN C stated she could barely get R1 to drink 1/2 of a supplement, and this was her norm. RN C stated CNA D called her on the phone at approximately 4:20 AM when she was walking to get a pop. RN C stated she immediately went to R1's room. RN C stated she arrived to R1's room in 1-2 minutes at the most. Surveyor asked if RN C was aware that R1 was a Full Code. RN C stated, Yes, correct. RN C stated you could clearly see that R1 had been deceased , had absolutely no color, gray in color. RN C stated she felt R1, and she was cold to touch. RN C stated that she lifted R1's arm up and it was somewhat stiff, not full rigor or anything like that. RN C stated she contacted LPN E and Physician F. RN C stated, she knew R1 was fine at 2:00 AM when CNA D checked on her. RN C stated she asked Physician F if she wanted her to start CPR? Physician F stated R1 is clearly gone, do not start CPR. Surveyor asked RN C how long have you worked at the facility. RN C stated 2 1/2 years PRN (as needed). RN C stated she usually works 2 shifts per month. Surveyor asked RN C if the facility provided education regarding code status prior to this incident. RN C stated she completed education related to code status on the computer. Surveyor asked RN C where would she look first to find a resident's code status. RN C stated, in the MAR (Medication Administration Record). Surveyor asked RN C, does it indicate Full Code or DNR (Do Not Resuscitate). RN C stated, no, it's not clear as to whether the resident is a full code or DNR, she thinks there is a heart for full code but is unsure. RN C stated, when residents have passed previously (not at this facility) we knew they were dying. Surveyor asked RN C, did you have a discussion with DON B (Director of Nursing) regarding R1's code status approximately two (2) weeks prior to her death. RN C stated, yes, she discussed R1's code status with DON B as R1's condition deteriorated and has been changing for quite some time. RN C stated she thought R1's code status had not been looked at since [DATE]. Of note, R1's POST was re-signed by R1's APOAHC on [DATE] and was located in R1's hard chart in the nurses station. RN C stated R1's family was aware R1 was in the process of dying. RN C stated she expressed concerns to DON B that R1 is still a Full Code, and she is declining, not eating, has toes that look gangrene to her and R1 was not a candidate for surgery. RN C stated R1 has been having vaginal discharge for months as well. DON B told her this has been reviewed. RN C stated R1's family was aware that R1 is declining and still wants her to be a Full Code. RN C stated, I understand that we need to do CPR . Surveyor asked RN C why did you not start a code and perform CPR. RN C stated, it was obvious that R1 was already deceased for quite some time, if R1 was warm and had color she could call rescue and start CPR. Surveyor asked RN C, based on R1's decision together with her APOAHC to be a Full Code, should you have started CPR. RN C stated, when deceased for a while she left that up to the doctor. RN C stated, Yes, you normally would. RN C added R1 was cold and had been deceased for a while. Surveyor asked RN C if the facility provided education to you following this incident. RN C stated, They told me I should have started a code and have started CPR on her. RN C added, it really wasn't an education, they told me this is what I should have done. RN C added, the facility also told her the policy and procedure for code status is also at the nurses' station.On [DATE] at 2:28 PM, Surveyor spoke with CNA D. Surveyor asked CNA D to describe what occurred with R1 on [DATE]. CNA D stated, I've been having a hard time with this and added she has been a CNA since 1988. CNA D stated she checked on R1 at approximately 2:00 AM. R1 was sleeping fine. CNA D stated R1 has been declining in health for quite some time but she had no issues indicating that she was near death. CNA D stated she went back to R1's room at 4:00 AM or a little bit before. CNA D stated R1 is a quiet sleeper and does not make much noise. CNA D stated she turned the small light on and told R1 she was going to check to see if she needs to be changed. CNA D stated she observed R1's hands were purple. CNA D added R1 was under 6 blankets per usual. CNA D added R1 always sleeps under many blankets. CNA D stated R1's face was colder than normal and pale. CNA D stated normally after passing a resident's face is white so she could tell she passed. CNA D stated she went to RN C and told her there is a death in room (number). CNA D stated she had never seen RN C before. CNA D stated RN C responded by saying, Why did I pick up this shift and I've never had this happen, I don't want to do CPR on her. CNA D stated she thought R1 was a DNR (Do Not Resuscitate) and thought her code status had been changed. CNA D stated she checked R1's code status in her bathroom which had a green sticker indicating R1 is a Full Code. CNA D stated RN C tried to call LPN E but LPN E did not answer. CNA D asked RN C if she wanted her to find LPN E. RN C stated, yes. CNA D stated she saw LPN E walking down the hall and told her there was a death in room (number). LPN E instructed CNA D to call 911. CNA D asked LPN E if we are doing CPR. LPN E stated, yes. CNA D asked if she should grab the crash cart. LPN E stated, yes. CNA D stated that when she got back to R1's room, nobody was in her room. CNA D stated she pulled (untucked) R1's sheet to get her to the floor. CNA D stated that she didn't want to smash R1's head and added she is a pretty big lady. CNA D stated that she saw RN C on the phone and assumed she was talking to the doctor or 911. CNA D asked LPN E if we are doing CPR. LPN E stated, no, the doctor said no CPR. Surveyor asked CNA D when she had most recently received CPR training prior to this incident. CNA D stated she had training in CPR approximately 1-1 1/2 months ago. CNA D stated the facility did mock drills with a manikin and EMS (Emergency Medical Services) was here. Surveyor asked CNA D, since this incident with R1 has the facility provided further training related to CPR. CNA D stated, Oh yes! Surveyor asked CNA D what would you do differently if this situation presented itself again. CNA D stated, if a resident is pulseless and not breathing, she would check the CNA Kardex in the resident's bathroom for a red (DNR) or green (Full Code) sticker. CNA D stated, if the resident were a Full Code, she would use the emergency staff button, get R1 to the floor or use a board under her and start CPR. CNA D stated she is CPR certified. CNA D stated again, she thought R1's code status had been changed to DNR. CNA D stated, if a resident is a DNR we do not use the emergency staff button. On [DATE] at 2:00 PM, Surveyor spoke with LPN E . LPN E stated she was working on the 200-300 wing when CNA D said there was a code on the 400 wing at approximately 4:00 AM. LPN E told CNA D to grab the crash cart and went down to R1's room. RN C was there. LPN E stated she planned on doing CPR and was looking for a pillow to put under her knees. LPN E stated to RN C , we have to start CPR on someone that's a Full Code. LPN E added, she was in between a rock and a hard place because RN C is the Registered Nurse. LPN E stated, I didn't know what to do. LPN E stated, RN C said R1 was cold. LPN E stated, she touched R1's face and arm. LPN E stated she wasn't ice cold but cooler than she was. LPN E stated RN C called Physician F and Physician F stated to not do CPR. LPN E stated we should have started CPR anyway and then RN C could have called the Physician F. LPN E stated, I did know what to do when it came right down to it. LPN E stated when the RN called Physician F before starting CPR that's where the confusion came in. LPN E stated she's careful about not overriding the RN . LPN E stated since this incident, NHA A has given her permission to override any RN when a resident is a Full Code and CPR needs to be started. LPN E stated the facility provided education to her regarding CPR on [DATE], her next scheduled shift. LPN E stated the facility also provided education to staff that when a resident is a Full Code staff are to do CPR unless the resident is decapitated.On [DATE] at 12:25 PM, Surveyor spoke with Physician F. Surveyor asked Physician F to describe the phone call she received from RN C on [DATE] regarding R1. Physician F stated RN C called her on [DATE] at 4:17 AM. RN C stated staff checked on R1 and R1 clearly had passed in her sleep. Physician F stated RN C felt R1's extremities were cool and there was an absence of vitals. RN C told her R1 is a Full Code. Physician F stated that she asked RN C, What are you supposed to do? Physician F stated RN C responded by saying, I'm not sure because she (R1) has clearly been passed a while. Physician F stated, 2:00 AM is R1's last known well time. Physician F stated that she asked RN C how was R1 doing up until this. Physician F stated she had not heard anything (concern/change in condition) about R1. Physician F stated, RN C told her R1 is in her usual state of health with no changes. Physician F stated R1 had gangrene of toes that can't be fixed due to poor blood flow and a bad heart. Physician F stated, R1 was in her stable poor health. Physician F stated, RN C was hesitant to start CPR as it was clear R1 had died a long time before she was found. Physician F stated RN C was confident R1 had passed and passed for a while. Physician F stated, RN C felt it was inhumane to do CPR on a resident that had passed possibly over 1 hour ago. Surveyor asked Physician Fif the facility provided education to you after this incident. Physician F stated, yes, NHA A and DON B informed her staff should have started compressions (CPR) due to R1 being a Full Code even though medically it makes no sense. Physician F stated, NHA A and DON B informed her that RN C and staff should have started a code and called EMS. On [DATE] at 3:15 PM, Surveyors spoke with NHA A . Surveyor asked NHA A, on [DATE] when R1 was found pulseless and not breathing should staff have started CPR and called EMS . NHA A stated, yes, R1 was a Full Code. NHA A stated she was made aware of RN C not performing CPR on [DATE] and informed SW L (Social Worker). SW L stated we needed to self-report the incident. NHA A stated facility staff have had frequent conversations since [DATE] regarding R1's code status. NHA A stated staff knew R1 was a Full Code and needed to do it (CPR). NHA A stated, R1 was adamant about being a Full Code. NHA A stated SW L has detailed notes regarding his discussions with R1 and her APOAHC regarding code status (referenced above). R1's APOAHC wanted R1 to be a Full Code. NHA A stated R1 refused hospice as she and her APOAHC didn't feel she was there yet. NHA A stated that CNA D had stated R1 was still warm. NHA A stated that LPN E went to the unit and RN C told her we're not doing it (CPR). NHA A stated the facility suspended RN C prior to terminating her employment on [DATE]. NHA A stated, DSPS (Department of Safety and Professional Services) may investigate. NHA A stated it is not our decision whether CPR is performed. NHA A stated, ultimately, we don't need to agree with it (a resident's right to choose their code status), but we need to follow it. NHA A stated she educated Physician F and R1's PCP . NHA A stated, R1's PCP was not aware of the process for CPR and NHA A added, she was really surprised by this. NHA A stated, our residents have a right to choose, and we need to follow their wishes. NHA A stated the facility completed mock drills and debriefed with staff after the drill. NHA A stated the facility educated staff that when a resident is a Full Code, pulseless and not breathing, staff need to do CPR unless the resident is decapitated. NHA A stated, when a resident that is a Full Code is cold and pulseless that is not a reason to not start CPR. NHA A stated R1 has vascular issues which can also make her hands cold. NHA A stated R1 had 1 warm hand and 1 cold hand. NHA A stated she called RN C on [DATE] to terminate her employment. NHA A stated that's when RN C admitted R1 wasn't fully cold. NHA A stated Human Resources was her witness during this conversation. NHA A stated, R1's face and 1 hand was cold which means she died more recently than we thought. NHA A stated she told RN C, that means we can't employ you. NHA A stated, she educated staff that if an RN refuses to do CPR on a resident that's a Full Code they can jump in an do it. NHA A added that the night shift CNAs are also CPR certified. NHA A added, RN C had a conversation with DON B that she was not happy with R1's code status. DON B educated RN C that R1's code status is the resident's choice. NHA A stated, we don't have to like it, but we have to follow through with R1's wishes. NHA A stated, based on her conversation with RN C, RN C has no sadness or remorse. NHA A stated, ultimately neglect is neglect, and she cannot employ RN C. Surveyor asked NHA A if RN C expressed concerns regarding all residents that elect to be a Full Code or specifically R1. NHA A stated, just R1. NHA A stated, we are not playing God here. The failure to provide basic life support including CPR, created a reasonable likelihood for serious harm, which created a finding of Immediate Jeopardy. The facility removed and corrected the immediate jeopardy on [DATE] when it completed the following:On [DATE], NHA A created education in regard to the F678 regulation (Cardio-Pulmonary Resuscitation) as well as the policy and placed for nursing staff to review and keep a copy. Nurse managers were given a scenario-based questionnaire to go over with nursing staff to ensure proper understanding of their roles during the code event.On [DATE], DON B reviewed all code statuses to ensure that all care cards in their room properly reflected their code status. SW took the audit and went room to room to ensure they were correctly placed on the care cards.On [DATE], Audit completed to ensure that there were no other events in the last 6 months. No other events were noted.On [DATE], Medical Director reviewed chart and stated that he didn't see anything wrong with the chart but more so that they did not start CPR.On [DATE], Audit of the Crash Cart and AED (Automatic External Defibrillator) machine completed by RN , and on a rolling schedule 3x (times) weekly for a month.On [DATE] CPR drill was started with all shifts and will continue until majority of the staff are in a mock drill. This is completed at random, and staff are not aware of the event occurring.On [DATE], Resident rights in regard to Code Status was given to staff during the CPR code drills. Staff were asked to demonstrate and tell us where they can locate the code status for staff, and real time education given to staff if needed.On [DATE], Nursing meeting held, were given the CPR scenario, and education provided on regulations and residents right to choose their code status as well as the policy in regarding to CPR.On [DATE], Audit of all CPR certifications completed. All staff who are working or scheduled to work are in good standing and all have completed in person certification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice for 2 out of 8 total sampled Residents (R4 and R5). Staff failed to recognize a change of condition in R5 until the Nurse Practitioner (NP) assessed the patient. Facility staff did not assess and monitor R5's condition as ordered by the physician. R5 was not sent to the emergency room (ER) per the NP's directive until 22 hours later, by which time R5's condition had worsened, resulting in R5 being admitted to Hospital where R5 was diagnosed with Sepsis, Pneumonia, and Acute Respiratory Failure with Hypoxia. R5 passed away two days later at the hospital. R4 was reporting irregular heart rates when an on-call physician gave orders to transport to the emergency room if apical pulse was greater than 115, the facility did not assess R4 or monitor R4's pulse for the next ten hours. R4 presented with irregular heart rate of tachycardia (fast heart rate) and bradycardia (low heart rate) and the facility sent R4 to the hospital via taxi vs. a medical transport service. Facility failure to recognize an acute change in condition, failure to closely monitor and assess a Resident with an acute change in condition, and failure to send a resident experiencing a significant condition change to the emergency room via ambulance rather than taxi created a finding of Immediate Jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator), DON B (Director of Nursing) of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity of a D (potential for more than minimal harm/pattern) as the facility continues to implement its action/corrective plan. This is evidenced by: The facility policy titled, Change of Condition, Resident, last revised [DATE], states in part . PURPOSE: To ensure timely assessment, documentation, RN (Registered Nurse) notification, physician notification, care planning, and resident/legal representative notification of significant change in the resident's physical, emotional, or psychological condition. POLICY: All staff members shall communicate any information about a resident's condition that could potentially indicate a significant change of condition to the resident's nurse. The nurse will gather data on the resident's condition and as appropriate, provide timely notification to the RN (Registered Nurse), if nurse is an LPN (Licensed Practical Nurse), the Physician/Medical provider, Resident of Legal Representative (Activated POA (Power of Attorney) or Legal Guardian). In the event that the RN is not available in-house, the RN on-call will be notified via phone for consultation. Other family members will be notified upon consent of the resident/legal representative. THE FOLLOWING ARE EXAMPLES OF CHANGES IN RESIDENT CONDITION: b. Changes in respiratory status including altered respiratory rate, oxygen saturation, breath sounds, or complaints of shortness of breath. k. Blood pressures that exceed the resident's established parameters or other symptomatic blood pressure variations. z. All infections/symptoms of infection. aa. Pain. New pain or changes in pain location, quality, intensity. PROCEDURE: a. All staff will report any observed or reported changes to the nurse caring for the resident, or the nurse supervisor/manager immediately. Should an MA (Medication Aide) be working on the household, they also should report changes of condition to the nurse and the process below will take place. The nurse can delegate tasks to the MA, within their scope/skill set, but the nurse is responsible for ensuring that appropriate care and assessment takes place./ b. The nurse will observe the resident, gathering subjective and objective data. Vital signs will be obtained /as appropriate for the condition. (Nurses are highly encouraged to use the AMDA (now known as PALTmed (Post-Acute and Long-Term Care Medical Association)) took. PROTOCOLS FOR PHYSICIAN NOTIFICATION, available at each nursing station to assist them in gathering the appropriate data before physician notification.) d. The nurse will notify the physician in a timely manner, documenting the notification, actions taken, and any new order received. Should an RN not be in house, this need not wait for RN consultation in emergency situations. *SPECIFIC SITUATIONS THAT INDICATE IMMEDIATE NEED FOR RN/MD NOTIFICATION: New onset of respiratory distress. NOTE: In the event that it is after clinic hours and the on-call MD cannot be reached within a reasonable time, the resident's primary MD should be contacted. If at any point the change of condition becomes emergent and the MD cannot be reached for orders, the nurse may elect to call the EMS (Emergency Medical Services) and notify the ER (Emergency Room) of the pending admission. h. Initially, changes in condition and related observations/assessments will be documented every shift in the nursing notes. Upon assessment of the nurse manager, documentation will continue at specified intervals until the problem resolves. Facility provided Surveyor with document from PALTmed, titled Acute Change of Condition in the Long-Term Care Setting, which states in part . Vital Signs: Report Immediately: Systolic BP (blood pressure) >(greater) 210 mmHg (millimeters of mercury) Diastolic BP >115 mmHg Resting pulse >130 bpm (beats per minute) or >110 bpm and patient has dyspnea or palpitations Chest pain: New onset or recurrent, not relieved in 20 minutes by previously nitroglycerin x (times) 3. Accompanied by change in vital signs, diaphoresis, nausea, vomiting, shortness of breath. 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 . Example 1 R5 was admitted to the facility on [DATE] with an Activated Healthcare Power of Attorney (AHCPOA). R5's diagnoses include in part . Diabetes Mellitus, Type 2, muscle wasting and atrophy, dementia, post traumatic stress disorder (PTSD), tremor, acute kidney failure, chronic kidney disease stage 4, peripheral vascular disease (PVD). R5's Quarterly MDS with an Assessment Reference Date (ARD) of [DATE] states in part . Brief Interview of Mental Status (BIMS) 10, indicating R5 had moderate cognitive impairment. Section E0100 indicates R5 has delusions but no other behaviors. Nursing Progress Note from [DATE] at 16:32 (4:32 PM) states, Spoke with Dr. (Doctor) regarding R5's back pain at 1205 and new orders given: -Lidocaine 4% adhesive patch as needed for back pain. Remove after 12 hours. -Mylanta-30mL (milliliters) by mouth every 4 hours as needed for GI (Gastrointestinal) upset. Suggested trying Mylanta because sometimes heartburn can cause mid-back pain. Orders faxed to pharmacy after they were received. Of Note: No vitals, or any type to assessment documented at this time. Of Note: There are no further assessments or vitals taken for R5 between [DATE] at 4:32 PM and [DATE] at 1:32 PM. Nursing Progress note from [DATE] at 13:32 (1:32 PM) states, R5 complained of mid-back pain this morning when he was getting up out of bed. Lidocaine patch placed and Mylanta given, and Tylenol given. Later stated that it helped. Followed up with him again at lunch time and stated that he had a little bit of pain but, not too bad. Did not want anything more for pain. At 1330 writer called to room by CNA (Certified Nursing Assistant). R1 was sitting on the toilet and complaining of back pain again. He stated that it was terrible. When asked to rate his pain with a number he stated 10/10. Writer asked him if he would like to be seen in ER (Emergency Room) today or if he would like to try to get an appointment tomorrow for someone to look at his back. He stated he would like to wait for an appointment tomorrow. I let him know that I would call his son and call the on-call physician. Nursing Progress Note from [DATE] at 1338 (1:38 PM) states, attempted to call HCPOA (Healthcare Power of Attorney) but he did not answer. On [DATE] at 13:56 (1:56 PM), R5's documented VS (vital signs) are, pain 10/10 (10 out of 10), 02 sat (oxygen saturation) 89% (percent), R (respirations) 20, pulse 104, T (temperature) 98.2, BP 181/76. Nursing Progress Note from [DATE] at 1414 (2:14 PM) states, On-call MD (Medical Doctor) called and updated, after explaining the situations. She asked for a set of vitals. While obtaining vital signs, R5 and I discussed about the ER or appointment tomorrow again and he still stated that he would prefer to have an appointment tomorrow vs the ER. Vitals within his normal limits except O2 sat was running 88-89%. He does appear to be a little short of breath, lungs sound clear. He denies any feelings of SOB (shortness of breath). Looking back in his history it appears that his O2 sats run 92-96%. HPOA returned call and we discussed options and R5's preference to wait for an appointment tomorrow. HPOA stated that he would like us to monitor him for a few hours and if it gets any worse that he would like him evaluated in the ER as he is concerned about his kidneys as R5 does have kidney failure and is waiting for a nephrology consult through University of Wisconsin. Called MD back to update her on vitals and discussion with HPOA. Reviewed labs that were done [DATE]. She is ok with HPOA's decision to monitor for a few hours and if he is getting worse to have him evaluated in the ER. There is no documented evidence that staff monitored R5 over the next few hours. Progress Note from [DATE] at 2138 (9:38 PM) states, R5 calling out a lot most of shift, saying Help me, help me . Staff go in and ask what he needs help with, and resident states I don't know. He does not seem to be more content if there is someone sitting in his room with him. Resident given Tylenol when able to help keep comfortable throughout shift. Resident is calm and quiet and resting in his bed at this time. (Med Tech) Of Note: The above note was written by a Medication Aide (MA). R5 has no assessments or vitals completed between [DATE] at 1:56 PM and [DATE] at 11:34 AM (21.5 hours). Nursing Progress Note from [DATE] at 11:34 AM states, in this morning when resident was in the dining room this writer asked how he is doing and he states, fine denied pain, denied back pain. After breakfast this writer did VS: BP 192/87, P94, O2 90-91 at RA, R 98.3. Resident denies pain, denied chest pain, no SOB (shortness of breath) at this time. Lungs auscultated and bilaterally lower lobes wheeze observed. Nurse practitioner present in resident's room and suggested to be sent to ER for further evaluation. Charge nurse notified; PO (power of attorney) notified. Of Note: This is the first set VS or assessment documented since [DATE] at 1:56 PM. Hospital ER Note from [DATE] states in part . HPI: 101 y.o (year old) M (male) who presents with dyspnea and wheezing found today at the nursing home. History of dementia, kidney disease not chronically on albuterol. No fever. VS: T 97.1, P 97, R16, BP 209/89, O2 92% Physical Exam: Calls out please multiple times. Lungs: expiratory wheezes bilateral left greater that right. Psych: slightly anxious. ED (emergency department) Course and Medical Decision Making: In this patient with dyspnea, I have considered multiple etiologies. Heart failure certainly a possibility, he satting [sic] 92% on RA. He is hypertensive. [NAME] count 17, 5 bands 84 segs, potassium 5.7, has chronic hyperkalemia, BUN (blood urea nitrogen) 103, creatinine 5.3, slightly worse than normal for him. Chest x-ray shows left base infiltrate. IV (intravenous) Rocephin and Zithromax given. Admit given age and increased risk. Hospital History and Physical (H&P) from [DATE] states in part . In ED (emergency department): Afebrile, heart rate 97, blood pressure 219/89, RR (respiratory rate) 16, WBC (white blood cell count) 17, Hemoglobin 10.4, platelets 282, sodium 135, potassium 5.7, creatinine 5.3, GFR (glomerular filtration rate) 9, BUN 103, glucose 373, BNP (B-type natriuretic peptide) 384, chest x-ray concerning for left basilar infiltrate. Plan: Sepsis, Pneumonia, Acute Respiratory Failure with Hypoxia. -meeting criteria for sepsis with tachycardia + (positive) leukocytosis (increased white blood cells indicating infection) and source being pneumonia. Associated with acute on chronic kidney injury. -Currently on 2L (liters) to maintain sats >90%, received Rocephin and azithromycin in ED. -Currently hemodynamically stable, will check lactic acid and send blood cultures. Continue with Rocephin and azithromycin. Hypertension: significant elevated BP, will add low-dose hydralazine Acute on chronic kidney disease, hyperkalemia (elevated potassium), acidosis: Hx (history) of CKD4, cr (creatinine) 5.3 up from previous 4.4, K (potassium) 5.7 and bicarb 16; IVF (intravenous fluids), monitor strict I&O (intake and output), K down from previous 6; repeat BMP (basic metabolic panel) R5 expired on [DATE] at the hospital. On [DATE] at 12:50 PM, Surveyor interviewed NM C (Nurse Manager). Surveyor asked NM C what his expectations were for a resident who was to be monitored. NM C stated, if a resident is to be monitored would expect VS, cognition, pain all that every hour. On [DATE] at 1:00 PM, Surveyor interviewed RN G (Registered Nurse). Surveyor asked RN G if she remembered R5 and what she remembered from the day he was sent to the hospital. RN G stated, R5 was bad the previous day (before being sent out) and I called his son (AHCPOA) and told him R5 didn't sound good and asked if he was okay with sending him to the hospital. Surveyor asked RN G if she remembers how R5 was transported to the hospital. RN G stated, I can't remember if R5 was sent by ambulance or taxi. Oh, I remember now, R5 was sent to the hospital via taxi. I remember because the hospital called and said R5 should have not been sent via taxi. I should have called an ambulance. Surveyor asked RN G what SOP (standard of practice) the facility uses. RN G stated, I am not sure. Surveyor asked RN G if should be monitored, what would you expect to be done. RN G stated, check VS, lung sounds, pain level with VS q (every) 1 hour but check on them every 15 minutes. On [DATE] at 1:50 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how staff determine what to use for transportation when sending a resident out to the hospital. DON B states we would need an order from MD then update family. Typically, if a resident is going to ER, we will send by ambulance. Surveyor asked DON B if a resident is to be monitored what her expectations would be for monitoring. DON B states I would expect staff would be doing lung sounds, VS, pain monitoring, turgor. Surveyor asked DON B how often that should be done. DON B stated, at least every hour. Surveyor reviewed R5's note indicating R5's son/AHCPOA wanted him monitored for a few hours then would make a decision on sending to the ER. Surveyor asked DON B if she would have expected staff to monitor R5. DON B stated, I would have expected more. DON B stated I would expect RN to be monitoring or MA (medication aide) to report to RN any data she collects or observations made. On [DATE] at 2:10 PM, Surveyor interviewed RN D (Registered Nurse). Surveyor asked RN D what monitoring of a resident for change of condition can be done by an MA. RN D stated, the MA should follow up on the residents status. Surveyor asked RN D what expectations for monitoring would be for the MA. RN D states check on the resident more frequently, probably every 1 hour and asking how they are doing. If concerns, then would report to another nurse, then VS and report and document what seeing. Surveyor asked RN D how staff determine what type of transportation the facility will use when transferring a resident to the hospital. RN D states if the resident is stable and going to the clinic I would send via taxi. If a resident is going to the ER I am sending them via ambulance. Surveyor asked RN D what SOP (Standard of Practice) the facility uses for change of condition. RN D stated, I don't know off the top of my head. On [DATE] at 2:25 PM, Surveyor interviewed CNA/MA E. Surveyor asked CNA/MA E what you would need to do when told a resident needs to be monitored. CNA/MA E states I would have to update the charge nurse, charge nurse completes any paperwork and MD notification. Check on the resident making sure nothing out of the ordinary, check VS and report changes. There is always an RN in the building when I am working. I would go to any floor RN with concerns if charge nurse is not here. Surveyor asked CNA/MA E if she had checked on or monitored R5 during her shift. CNA/MA E states there was nothing out of the ordinary that I can remember and if I didn't chart or anyone else didn't chart then it wasn't done. If a resident needs more frequent vitals it would be put in the MAR (Medication Administration Record)/TAR (Treatment Administration Record). On [DATE] at 3:30 PM, Surveyor interviewed NP F (Nurse Practitioner). Surveyor asked NP F if she could recall what R5 was presenting like. NP F stated, I saw him on [DATE] for my rounds and then again [DATE]. He was not on the list to be seen but staff were concerned and asked me to look at him. R5 reported when I saw him that he was more SOB (Short of Breath) but did not appear to be. I believe he requested to go out and I told staff that if he wanted to go to send him. I didn't feel that it was imminent. I was told his vitals were stable. Surveyor asked NP F if staff were to be monitoring R5 what her expectations would be for monitoring. NP F stated, I would expect them to monitoring lung sounds, VS, SPO2 (oxygen saturation) and checking on him every 15 to 30 minutes. Surveyor asked NP F if R5 had a known history of calling out. NP F stated, R5 did call out often due to PTSD (Post Traumatic Stress Disorder). Surveyor asked if she thought that R5 being transferred to the hospital by taxi was appropriate. NP F stated, I think that might have been okay but with my experience I wouldn't send via taxi. I don't know what was all going on. Of Note: NP F did not complete a progress note on [DATE] when she saw R5. During interview NP F indicates she is going off memory as she had no notes on the visit. Example 2 R4 admitted to the facility on [DATE]. R4's diagnoses include in part: Unspecified atrial fibrillation, muscle wasting and atrophy, Acute diastolic (congestive) heart failure, Hypertensive heart disease with heart failure (heart issues that develop due to long-term high blood pressure), Atherosclerotic heart disease of native coronary artery without angina pectoris (damage or disease in the heart's major blood vessels without chest pain), localized edema, venous insufficiency (chronic) (peripheral), Unspecified atherosclerosis of native arteries of extremities (buildup of substances in and on the artery walls), and long term (current) use of anticoagulants. R4's Brief Interview for Mental Status (BIMS) was 12 out of 15 on the most recent Minimum Data Set (MDS) dated [DATE], which indicates R4's cognition is moderately impaired. R4 is her own decision maker. Nursing progress notes for R4 include, in part: Dated [DATE] at 4:50 AM, Resident was up to bathroom at 0430 with assist and walker, then returned to recliner, apical pulse (the heartbeat as it is felt at the apex (bottom) of the heart) 112 after walking to and from bathroom and continues with irregular that is fairly regular. States she feels tired and reminded her of time and she could sleep some more before having to get up for the day. Dated [DATE] at 2:31 PM, Resident denied weakness or dizziness this morning and stated when asked that she felt fine. Apical pulse this shift: 96 bpm (beats per minute) and continues to be irregular. Resident notified writer after her appointment, nearing the end of the shift, that she had experienced chest pressure this morning and sometime yesterday. Resident educated to notify staff immediately if this occurs. Resident stated it went away after drinking some fluids. Resident denied having any chest pressure or pain at this time. VS (vital signs) obtained and were stable, with the exception of irregular pulse. Resident's PCP (Primary Care Provider) is not in office. Writer attempted several times to notify on-call MD (Medical Doctor) without success. Left voicemail requesting to return call. On-coming nurse made aware. Will continue to monitor. Dated [DATE] at 4:48 PM, On-call MD returned call and was updated on resident history and situation. Stated that resident either needed to go to urgent care or to be seen by a provider sometime this week. Stated if apical pulse goes above 115 needs to go to urgent care/ER (Emergency Room) or receive treatment. Writer talked with resident. Resident stated that she was fine for now and did not want to go to ER at this time. Writer informed resident to let staff know if decides otherwise. Writer put resident down on physician rounds to be seen this week. Charge nurse is aware. It is important to note no other assessments were completed on R4 until 5:00 AM the next morning, which is about a 14.5 hours since the last assessment and MD stating to send R4 to the ER if her heart rate went above 115. Dated [DATE] at 6:29 AM, Residents HR (heart rate) upon awakening at 0500 was elevated with short bursts of tachycardia followed by short periods of bradycardia. HR was difficult to determine d/t (due to) erratic and rapid nature, but it did elevate to upwards of 120 when auscultating (using a stethoscope) but showing in the 90's on the pulse ox (pulse oximeter, an electronic device that measures the saturation of oxygen carried in your red blood cells and pulse). Resident is anticoagulated with Eliquis but does not at this time have a medication for rate control. PCP (primary care provider) office was notified via voicemail d/t the early hour, and the next shift was notified of these findings. Resident was informed of this, and she did state that she would be interested in having this treated since she is having some chest tightness with these episodes. Of note, R4 is presenting symptoms of tachycardia followed by bradycardia with a heart rate elevating to 120 and R4 is having chest tightness with these episodes at 0500. On call doctor stated the previous day R4 needs to go to urgent care/ER if apical pulse goes above 115, R4 stated she wanted to be treated. Facility left another voicemail for primary doctor without attempting another method of speaking with a physician. Dated [DATE] at 9:51 AM, VM (voicemail) left with Dr. [name]'s office asking if the physician would be willing to see the resident today when he is in the building for rounds on one of his other patients. Awaiting return call. Dated [DATE] at 10:52 AM, Writer was informed by clinic staff that this resident's PCP is out of the office until the end of February, note charge nurse had placed a call to Dr. [name] asking if would see R4 while here for rounds with a return call received that Dr. [name] will see her today while in facility doing his rounds. Unit clerk faxing requested information to Dr. [name]s office to review prior to seeing her today. R4 updated on being seen at facility today. Apical HR 110 irregular after morning shower. Stated at times she has some chest pain and pointed to her mid sternum area when asked where, denied any type of radiating pain or back pain, denied shortness of breath, vertigo, or angina (chest pain) thus far today. Dated [DATE] at 1:01 PM, Continued to deny chest pain throughout the day. Dated [DATE] at 3:00 PM, Resident resting in recliner. Denies pain at this time but shared with writer that she had CP (chest pain) this morning and did not report it. VS as follows. Temp 98.0, HR 122 and irregular, resp 22, B/P 130/87 and sat 98% on RA. 1 + edema to lower extremities. R>L. Breath sounds with crackles to right base. Denies CP at this time. Dr. [name] in house and assessed. Order received to send to ER. Writer spoke with Dr. [name]'s MA (medical assistant) per his request to report VS. Writer also called Hospital ER and report given to nurse. It is important to note the in-house doctor assessed R4 10 hours after nurse noted R4 was presenting episodes of tachycardia and bradycardia, chest tightness, and a HR of 120. Dated [DATE] at 4:06 PM, HUC (health unit clerk) took resident to front office with scheduler at approximately 3:30 PM. Resident left facility around that time. Of note, this progress note does not specify how resident was transported to the hospital. Surveyor interviews with staff indicate resident went to the hospital via taxi. Dated [DATE] at 5:09 PM, Call from ER. Resident given 120mg Diltiazem with effective results. New order received for Diltiazem 120mg daily in the evening for BP/heart rhythm control. Potassium level was slightly low and troponin level slightly elevated but physician wasn't concerned with these lab results at this time as resident has reported chest discomfort as of late. Resident returning via taxi service soon. Dated [DATE] at 10:14 PM, Resident returned from hospital via taxi at approximately 5:20 PM. Ate toast and had coffee. Took scheduled medications. Denies CP (chest pain). HR (heart rate) 89 and irregular. Surveyor reviewed the ER report from [DATE]. It states, in part: presents with rapid heart rate on and off this week, she says is worse in the morning and then it resolves, does have a history of A-fib (irregular heart rate). Denies any pain, says she can feel her heart racing in the morning and that it seems to stop. EKG: A-fib RVR (rapid ventricular response) with a wide complex. ED Course and Medical Decision Making: Emerged from her course consisted of 5mg verapamil, her heart rate came from the 160's down to the 90's, patient felt better, will discharge home, diagnose A-fib RVR. She will be started on Cardizem CD 120mg p.o.(by mouth) nightly, follow-up with her doctor, return for worsening symptoms. Patient was resting comfortably here in the Emergency Department. Prescriptions: New Diltiazem HCl 120mg capsule, extended release 24 hr - 120mg PO daily. On [DATE] at 1:23 PM, Surveyor interviewed RN H (Registered Nurse) regarding how R4 got transported to hospital on [DATE] as her nursing note did not specify the transportation used. Nurse stated she wasn't sure which transportation service was used, stated the charge nurse, RN C, took care of the transportation. RN H stated she remembers resident coming back to facility via taxi on [DATE]. On [DATE] at 1:35 PM, Surveyor interviewed RN C and asked how resident was transported to the hospital on [DATE]. RN C indicated an ambulance was used and gave Surveyor the phone number for the ambulance service. On [DATE] at 2:04 PM, Surveyor called the ambulance service and they told Surveyor no call was placed from the facility on [DATE], stated they didn't go to the facility at all on [DATE]. On [DATE] at 2:18 PM, Surveyor interviewed RN C again to ask if it was possible a different ambulance service was used to transport resident. RN C stated no, it would have been the one he told Surveyor prior. Surveyor then asked if it was possible a taxi service was used to transport resident to hospital. RN C stated yes, it was possible and gave Surveyor phone number for the taxi service the facility uses. On [DATE] at 2:26 PM, Surveyor called the taxi service and the manager indicated they were called to come to the facility to pick up R4, left facility at 3:40pm and transported her to the ER on [DATE], arrived at ER at 3:51pm. Of note, R4 was presenting with symptoms of tachycardia (elevated heart rate), bradycardia (low heart rate), a HR of 122 and irregular, and R4 having chest tightness with these episodes. Facility chose to send the resident to ER via taxi instead of an ambulance. On [DATE] at 5:35 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when contacting the physician for a residents change of condition, in what circumstances is it okay to leave a voicemail versus speak with a physician. DON B stated, A lot of times when we are calling the physician it is during office hours, so we are leaving a message and waiting for a return call. Surveyor asked DON B how long the typical wait was for the physician to return the call. DON B states, It depends. Surveyor asked DON B how long do staff wait for a return call before they contact another provider or send a resident out. DON B stated, That also depends on the situation. Surveyor asked when Standards of Practice indicates immediate notification to MD, is it okay to leave a message or voicemail. DON B stated, I don't think we have any option but to wait for them to call us back or we would just be sending out. Staff failure to recognize an acute change in condition, failure to closely monitor and assess a resident with an acute change in condition, and failure to send a resident to the hospital via ambulance rather than a taxi during an acute change of condition resulted in a delay of treatment and alternative interventions which created a finding of immediate Jeopardy. The Facility removed the jeopardy on [DATE] when it had completed the following: Staff education started on [DATE] in regard to Change in condition ie: what is a change in condition, how to recognize, appropriate response to COC, Physician notification as well as assessments required for COC.Staff are required to review prior to the start of their shift. Staff are educated to to assess the resident for the COC, gather Vitals, symptoms, changes above baseline condition, at a minimum of twice a shift or transferred for further evaluation. MD should notified upon the COC, vitals, symptoms, interventions, reactions, pain, infections,