Benedictine Living Community Owatonna

and NA changed R1's gown prior to paramedics arriving as it had a rancid smell to it. LPN-B called the

edited her progress note to add that R1 had pain 10/10.During a phone interview on 3/25/26 at 10:16

specific time. R1 had not been feeling well, had not eaten, and had some nausea. MD-A was aware of R1's elevated BP reading but that the reading had been obtained after R1 had an episode of dry heaving. MD-A advised RN-A to notify her later in the evening on R1's status. At that time, MD-A had not thought R1's condition was acute enough to send to the emergency department but deserved continual monitoring and rechecking of VS as a resident would not typically be sent to the hospital because of an upset stomach. MD-A's expectation was that an ambulance should be called right away immediately after the order to go to the emergency room was given.

During an interview on 3/25/26 at 12:59 p.m., Administrator and DON were present. DON stated with the VS taken at 6:43 p.m., she would have expected a focused abdominal assessment completed, especially after noting there was no bowel movement in the colostomy bag and MD notification with results of the assessment.

From VS taken at 9:10 p.m., RN-A should again assess R1, update MD if that had not occurred, update family, and begin transfer to emergency room process.

The ambulance should have been called when the order was obtained. At 10:17 p.m., DON would have expected the ambulance to be enroute to the facility and a nurse to stay with R1 until transport complete.An email dated 3/26/26 at 12:01 p.m., identified the facility did not have a policy regarding if an ambulance required lights and sirens but the determination was made by the ambulance company when it was triaged.

The facility does not have a policy on administering newly ordered medications for a change of condition.The facility Change in Condition, Resident Examination and Evaluation dated 11/10/25, identified a thorough resident examination and evaluation will capture any abnormalities in health status, physical function, or an acute change of condition.

When a significant change in the residents physical, mental, or psychosocial status is identified by licensed nurse, the license nurse consults with attending provider and notified the resident/resident representative.

Obtain VS and repeat as needed or ordered.

Notify the provider of change in condition and implement orders for treatment and appropriate monitoring as directed.

Notify the resident/resident representative.

Document symptom(s), assessment, observations, resident/resident representative, and medical provider notification.

Monitor and provide treatment as ordered by the attending provider.