**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. This occurred for 1 of 2 residents (R39) reviewed for physician notification and consultation. R39 presented with new symptoms of cardio-respiratory complications in addition to a significant weight gain. Staff did not immediately notify R39's provider of this occurrence resulting in R39 being admitted to the hospital 4/30 - 5/4/23, one week after the start of these symptoms, with a diagnosis of heart failure and atrial fibrillation with RVR (rapid ventricular rate). Findings include: The facility policy, entitled Notification of Change, revision date 7/21, states: .Significant changes in a resident's condition or treatment are promptly .reported to the attending physician or designee .Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident .Requirement of notification of resident's physician: .A significant change in the resident's physical, mental or psychosocial status in either life-threatening conditions or clinical complications .The nurse will notify the resident's physician for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician (utilize Interact 4.0 guidelines and nursing judgement) . The Interact Version 4.0 states: Change in condition: When to report to the MD/NP/PA (Provider) Immediate Notification: Any symptoms, sign or apparent discomfort that is: acute or sudden in onset, and: a marked change (i.e. more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Non-Immediate Notification: new or worsening symptoms that do not meet above criteria . R39 was admitted to the facility on [DATE] with diagnoses that included in part, Crohn's disease, major depressive disorder, hyperlipidemia, Alzheimer's, vascular dementia, cerebrovascular disease, paroxysmal atrial fibrillation post-surgery resolved (2016). 5/4/23: acute pulmonary edema, acute/chronic heart failure (CHF), atrial fibrillation with RVR. R39's provider orders: Prior to 4/30/23 - Aspirin 81mg daily for anticoagulant therapy. R39's provider notes in part: 3/27/23 Primary provider note indicated nursing staff do not report any acute concerns. No recent hospitalizations or ER visits in last year. Patient's weight is stable at 208 pounds. R39's nurse progress notes in part: 4/17/23 weight 205 pounds standing scale. 4/23/23 at 2:04 AM [R39] came up to the nursing station complaining of not feeling well. Skin is cool, moist and pale. She is able to talk and seems anxious and restless. Hands fly in the air when she tries to say exactly how she feels. Blood pressure elevated 160/93, pulse 95, O2 sat 95% RA, Temp 96.9 with hair wet from sweating. Respiratory rate 28. Given Tylenol and melatonin as she complains she can't sleep. Assisted back to her room and laid down with HOB (head of bead) slight elevated. She [R39] is now fast asleep. Unsure what the cause was. Denies chest pain but did say heavy. Pulse fast but regular. If she woke from a bad dream, anxiety, worry, dementia, unsure will monitor. *Note no provider notification completed. 4/24/23 at 12:55 AM The past two nights, [R39] has talked with the nursing staff about feeling restless and out of sorts. States I am tired but cannot sleep. Note occasional nonproductive cough, fine crackles in upper lung fields. Temperature 96.8, oxygen saturation 94% on room air. Sat at nursing station for 20 minutes. Gave her Tylenol and melatonin to help her rest. Will continue to monitor. Respirations audible wheezing, lung sounds crackles heard upon auscultation upper bilateral lobes, nonproductive cough. Continue to observe, encourage coughing and deep breathing, head of bed elevated, repositioned, encouraged to rest. Covid 19 test done: negative results. *Note no provider notification completed. 4/24/23 at 6:48 AM weight 212 pounds (weekly) standing scale - weighed x 2. *Note a 7-pound weight gain over one week along with two nights of new symptoms of cardio-respiratory complications. No provider notification completed. 4/24/23 at 10:43 AM Pulse 100, respiratory rate 24 and shallow, respiratory findings: shortness of breath or trouble breathing when sitting at rest (on room air), lung sounds: no wheezing noted. Resident on her way to activities like she does every day. I don't know why I am short of breath. *Note no provider notification completed. 4/24/23 at 11:24 PM Shortness of breath noted when talking and when self-propelling in hall. *Note no provider notification completed. 4/29/23 at 12:15 AM [R39] was escorted to nursing station this NOC (night shift) with complaints of chest heaviness and hard time breathing. Patient is being monitored. Blood pressure (b/p) 156/106, pulse 113, temp 96.8, respiratory rate 27. 4/29/23 at 12:25 AM feeling better, [R39] said she felt hot with shortness of breath. b/p 157/94, pulse 120, oxygen saturation 94% on room air. 4/29/23 at 12:35 AM b/p 151/94, pulse 121. 4/29/23 at 12:50 AM b/p 130/88, pulse 111. [R39] feeling better, back to her room with escort. Will monitor. *Note no provider notification completed. 4/29/23 at 11:48 PM b/p 137/83, pulse 121, respiratory rate 22, oxygen saturation 92% on room air. Patient requested to see RN (registered nurse), heaviness on chest while laying down and again when up right in her wheelchair. Lung sounds with wheezing bilateral upper lobes. Called on call provider: ordered on time Albuterol nebulizer treatment, if not effective to send to ER (emergency room). After treatment, [R39] stated feeling better, decreased wheezing on auscultation. Will monitor. 4/30/23 at 11:18 AM b/p 142/72, pulse 91, respiratory rate 22. [R39] was coughing quite a bit with breakfast. Dose sound audibly wheezy. Crackles in upper lungs. Denied shortness of breath. Did give her a prn (as needed) dose of cough medication with improved results. Weight is 214 pounds. Bilateral lower extremities with 2-3 + edema. 4/30/23 weight 214 pounds standing scale. Weight gain of 9 pounds from weight on 4/17/23. *Note no provider notification completed. 4/30/23 at 8:43 PM Writer was passing by [R39]'s room this evening and heard resident shouting, Someone help me, I can't breathe. Found resident to be visibly short of breath, resident skin was clammy, and hair was damp. Oxygen at 2 liters per minute started per nursing measure. b/p 183/133, pulse 150, oxygen saturation 97% (taken after oxygen applied), respirations 28. Resident is a full code. Dispatch notified and resident sent to the hospital. Provider and guardian notified. R39 was admitted to the hospital from [DATE] through 5/4/23 with a new diagnosis of congestive heart failure and atrial fibrillation with RVR. 4/30/23 Emergency department note indicated R39 was admitted to the hospital with a diagnosis of CHF and atrial fibrillation with RVR. R39 was started on a Cardizem infusion [to control the atrial fibrillation rate], and Lasix [to help remove excess fluid the heart was unable to pump out] injection. Chest Xray indicated central vascular congestion secondary to pulmonary edema with small right sided effusion. BNP (lab test for heart failure) level was 8,386. EKG indicated atrial fibrillation with RVR. 5/1/23 Hospital history and physical note indicated R39's significantly elevated BNP and pulmonary edema are indicative of heart failure likely secondary to her atrial fibrillation. Will continue further evaluation of her ejection fraction via TTE (transthoracic echocardiogram) in the morning and continue to pull off fluid with Lasix for now. 5/4/23 Hospital discharge summary note indicated R39's TTE result stated: the left ventricular internal cavity size was mildly increased. Concentric left ventricular hypertrophy. Moderately decreased left ventricular ejection fraction. Normal right ventricular size and ejection fraction. Left atrium appears severely dilated. Ejection Fraction of 33% and global hypokinesis. Weight at discharge 205 pounds 8 ounces. R39's physician orders post hospitalization on 4/30/23: Eliquis 5mg twice per day for cerebrovascular accident prophylaxis, Digoxin 125mcg daily for atrial fibrillation RVR hold for pulse less than 60, Lasix 20mg daily for chronic heart failure with reduced ejection fraction, Metoprolol ER 100mg twice per day for atrial fibrillation. On 3/26/24 at 1:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN) K and asked what the process for resident weights was if there was a weight increase. LPN K said some of the residents have orders to notify provider if 3 pounds in one day or 5 pounds in one week. Other residents have if the weight was increased, we would re-weigh the resident. If the weight was increased, we would do an assessment to look for edema and lung sounds and notify the provider and my supervisor. Surveyor asked if a resident complained of chest heaviness, restless, vital signs off what would you do. LPN K said she would think cardiac and would assess the resident, get vital signs, and notify the provider and my supervisor. On 3/26/24 at 2:15 PM, Surveyor interviewed RN J and RN H and asked if a resident had an increase in weight, what would be the process. Both RNs said we would reweigh the resident, assess the resident, start the fluid volume overload protocol, and notify the provider to see what to do for the resident. Surveyor asked RN J and H if a resident stated they had chest heaviness, restlessness, and elevated vital signs, what would you do. RN J said she would assess the resident and it all depends on the situation. If it was cardiac or anxiety. If it was only one time and the resident calmed down, there would not be an immediate notification to the provider but notify in the provider notification book. If the symptoms continued, then I would for sure notify the provider. Surveyor asked if R39 had a diagnosis of anxiety. RN J looked at R39's chart and RN H looked at R39's electronic record. Both RNs said R39 did not have a diagnosis of anxiety. On 3/26/24 at 4:11 PM, Surveyor interviewed Director of Nursing (DON) B and asked if a resident had an increase in weight what would be the process if the resident does not have a congestive heart failure (CHF) diagnosis. DON B said we would at least do a routine notify to provider about the weight gain every Monday. DON B looked up to see if this was done for R39 when R39's weight increased from 205 to 212 pounds. DON B said there was no notification to R39's provider. Surveyor and DON B looked at R39's nurse progress notes from 4/23/23 through 4/30/23. Surveyor asked DON B if provider should have been notified based on R39's signs and symptoms and weight gain. DON B said the expectation to notify provider was for the nurse to use their judgement. On 3/26/24 at 4:38 PM, DON B provided Surveyor with the policies and documentation requested. DON B said the only time R39's provider was notified was on 4/29/23 at 11:48 PM when they received an order for an Albuterol nebulizer treatment and again on 4/30/23 at 8:43 PM when R39 was sent to the hospital. On 4/1/24 at 10:40 AM, Surveyor interviewed R39's Medical Doctor (MD) P and explained the weight gain along with the signs and symptoms R39 developed from 4/23/23 through 4/30/23. Surveyor interviewed MD P asking what the expectation was for staff to notify the provider due to weight gain and new cardiac symptoms. MD P said with these symptoms and weight gain we would be concerned about heart attack, heart failure, or atrial fibrillation. When the heart rate was above 100, that would be concerning of atrial fibrillation. Weight gain is tricky, but with the combination of the weight gain and acute symptoms, I would expect the facility to notify the provider right away. MD P said she was not sure why the facility did not notify her or the nurse practitioner who visits the facility regularly concerning R39's weight gain along with acute symptoms. Surveyor asked MD P what you would have done if notified earlier of R39's weight gain and symptoms. MD P said anything concerning chest pain/heaviness and shortness of breath, we would send the resident out to be evaluated at the emergency department for possibility of heart attack, heart failure, or atrial fibrillation. MD P said she should have been notified when the symptoms started on 4/23/23 and would have sent R39 to the emergency department. Surveyor asked MD P would an earlier notification to you with earlier interventions for R39 result in less damage to the heart. MD P said this was hard to predict because it sounds like a gradual worsening onset. Also, what started first the atrial fibrillation or the heart failure. Atrial fibrillation puts a person at risk for stroke. Surveyor asked MD P how R39's cardiovascular status was now compared to before the hospitalization at the end of April 2023. MD P stated now R39 was prescribed Digoxin and Metoprolol (to control the atrial fibrillation rate), Lasix (to help remove excess fluid the heart was unable to pump out), and Eliquis (a blood thinner to prevent blood clots formed while the heart is in atrial fibrillation as there is a risk for stroke). MD P said R39 continued to be in the atrial fibrillation rhythm but does not currently have any edema or shortness of breath. R39's symptoms were well controlled on the current medications. MD P said she was surprised the facility did not notify her about this and allowed the symptoms to go on for that long. That was unusual for this facility.