Health inspection·January 25, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify the physician of low blood pressure for one of three residents (R3) reviewed for falls in a sample of three. Residents Affected - Few Findings Include: The Facility's undated Change in Resident's Condition or Status documents, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident/s medical. Mental condition and/or status. The policy documents The nurse will notify the resident's attending physician or physician on call when there has been a (an) d.) significant change in the resident's physical/emotional/mental condition and specific instruction to notify the physician of changes in the resident's condition. The Facility's undated Change in Resident's Condition or Status policy defines significant change as a major decline or improvement in the resident's status that a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention b) impacts more than one area of the resident's health status c) requires interdisciplinary review and/or revision to the care plan and d) ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. R3's Physical Therapy Treatment Encounter Note, dated 1/2/at 4:40 PM, documents, Pre-Tx (Treatment) Vitals assessed = Systolic/Diastolic Blood Pressure at rest/sitting 73/59, seated 82/50, and 75/43 after standing. R3's Physical Therapy Treatment Encounter Note, dated 1/2/24 at 4:40 PM, documents, Response to Tx (Treatment) response to session interventions. Consultation with patient's nurse to see if TED (Thrombo-Embolic Deterrent) hose can be applied/ordered for patient to assist with raising blood pressures due to orthostatic hypotension (low blood pressure when upright and standing). Patients nurse to call doctor. On 1/25/24, V3 (Physical Therapy Aide) stated, I had to stop (R3)'s therapy because he was dizzy, and his blood pressure kept dropping. (R3)'s blood pressure was dropping with minimal movement. I took him to his nurse (V5/Licensed Practical Nurse) and told her. On 01/25/24 at 2:10 PM, V5 (Licensed Practical Nurse) had handwritten notes she was referring to and stated, I have it written down that (R3)'s blood pressure was low, and therapy wanted the doctor called and wanted (R3) to sit up more. V5 stated she would have told the charge nurse. V5 stated, I only do medications; I don't chart or call doctors or families. I can see where therapy did tell me, Page 1 of 2 146033 146033 01/25/2024 Elms, The 1212 Madelyn Avenue Macomb, IL 61455

F 0580 but that information would have gone to the charge nurse that day. Level of Harm - Minimal harm or potential for actual harm On 01/25/24 at 1:30 PM, V4 (Registered Nurse/Charge Nurse) stated, I do not recall anyone reporting low blood pressure for (R3) to me on 01/2/24, I would have done an assessment. Residents Affected - Few On 01/25/24 at 1:15 PM, V7 (R3's Doctor) stated, I was not notified of the orthostatic hypotension (R3) was having in therapy on 1/2/24. I can say at the very least I would have ordered some further testing for (R3) if I had been. I may have sent him to the hospital. I have told them (Facility Staff) multiple times to call me at the first sign of any trouble with this guy because he tends to get sick very quickly. 146033 Page 2 of 2