**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review and document review, the facility failed to assure that all nursing staff possessed the competencies and skill sets necessary to provide nursing care to meet residents' needs in a safe manner. Specifically, the licensed staff did not demonstrate 1) competency to perform and document neurological (neuro) assessments on a Resident whose baseline was neurologically impaired, 2) competency to identify a medical emergency that required timely response and transfer to a higher level of care, and 3) critical thinking to recognize the need to conduct and document a thorough physical and neurological assessment after a fall with potential head/neck injury, to determine if the Resident could be safely transferred from the floor to the bed. Due to the serious nature of this citation, and the fact that multiple licensed staff were involved, and did not demonstrate competency, this deficient practice was determined to be an immediate jeopardy (IJ). The survey team approved the facility abatement plan and validated it had been implemented. If nursing staff do not possess the competencies and skill sets for the population served, it could affect any resident and place them at risk of adverse events, harm or death. Findings include: 1) The facility is a 36 bed facility that cares for pediatric and adult residents that have complex medical issues. There is a high volume of residents that have cognitive and physical disabilities and require complex respiratory support due to various causes. This resident profile requires that all nursing staff have special skill sets to meet residents' medical needs. At the time of survey, the census was 33, nine adults and 24 pediatrics. Reviewed the Facility Assessment Tool last updated 03/05/2025. The document revealed the following: Part 1: Our Resident Profile included Diseases/conditions, physical and cognitive disabilities. These conditions included, Neurological Problems, which was further broken down to include but not limited to Traumatic Brain Injury, Minimal Consciousness, Vegetative State, Seizure disorder, Communication Difficulty and Anoxic Brain Damage. Part 2: Services and Care We Offer Based on our Residents' Needs, included Management of medical conditions. The Specific Care or Practices for Management of medical conditions read Assessment, early identification of problems/deterioration, management of medical symptoms and conditions . Part 3.4 Staff training/education and competencies, included staff training/education and competencies are necessary to provide the level and types of support and care for the residents.Staff competencies are monitored by department supervisors and nursing's scheduler. The assessment included Supplies, which listed respiratory, medical and nonmedical supplies. It was noted the list did not include a pen light, which should be used for neurological assessments. 2) R1 was a [AGE] year old male with history of traumatic brain injury (TBI) with subdural hematoma (bleeding inside the head). He had a decompression craniectomy (part of the skull is removed to reduce pressure on the brain and allow swelling). As a result of his injury, R1 was a quadriplegic (paralysis of all limbs), had a tracheostomy (hole in neck to breath), and a PEG (tube into the stomach through the abdominal wall for feeding). On 03/16/2025 at approximately 08:20 PM, R1 sustained a fall from bed; reported while being changed by a Certified Nurse Assistant (CNA). He had altered mental status (AMS), and was transferred to the hospital emergency room (ER) by ambulance for further evaluation on 03/17/2025 at 02:20 AM. R1's cat scan (x-ray of head) was negative at that time, for acute traumatic injury and he was discharged back to the facility, that same day (03/17/2025) at 12:10 PM. On arrival back to the facility, R1 was assessed to have altered mental status (AMS) from his baseline and was subsequently sent back to the hospital a second time on 03/18/2025 at 09:42 PM. That hospital transferred R1 to another facility (referral center) for further management, where he was admitted with primary diagnosis of subacute encephalopathy, multifactorial (disease affects the brain and leads to AMS). Despite treatment of the suspected causes of the encephalopathy, his mental status did not significantly improve and he was transitioned to comfort care and ultimately passed away on 04/05/2025. 3) Reviewed Nursing documentation that included [NAME]-Daily Assessment (template documentation format) notes as well as Health Status Notes (progress notes) after the fall, to the time R1 was initially transferred to the ER. These records included the following: 03/17/2025 Note entered at 08:52 AM: @2020 (03/16/2025, 08:20 PM), CNA assigned to the resident was changing the resident's diaper when the resident fell on the floor. Upon assessment found one linear redness to the right upper forehead measuring 2 cm (centimeter) x 0.5 cm, skin intact. No other visual injuries noted.CN (Charge Nurse) and this nurse @ bedside. @20:30 (08:30 PM on 03/16/2025) resident awake BP (blood pressure) 130/86. HR (heart rate) 62 T. (temperature) 35.5 (centigrade) RR (respiratory rate) 22 Awake, alert. @ 2035 (08:35 PM on 03/16/2025) BP 145/84 HR 60 O2 (oxygen saturation) RR 22. @ 2052 (08:51 PM on 03/16/2025) x 1 desat (desaturation (drop in oxygen level)) to 86% . RT (respiratory therapist) placed the resident on RC 28% BP 127/87 HR 59 O2 99 T 36.6. @ 2031 (08:31 PM) DON (Director of Nursing) made aware. @ 2112 (09:12 PM ) Attempted to call the doctor on .CN (Charge Nurse) phone, no answer. @ 2020 (08:30 PM) BP 127/87 HR 59 O2 99 T 36.6. @ 2128 (09:28 PM on 03/16/2025) sent Dr (MD1) a message regarding an update on resident's status and also called physician exchange @ 21:32 (09:32 PM). @ 2145 (09:45 PM) BP 134/87 HR 55 O2 100 T 36.5. @ 2217 (10:17 PM) BP130/87 HR 53 O2 100 RR 20. @ 2252 (10:52 PM) BP133/82 HR 51 O2 99. @ 2325 (11:25 PM) BP 124/72 HR 53 O2 100 RR 18. @ 0000 (00:00 AM on 03/17/2025) RT weaned the resident back to RN (room air), BP 109/63 HR 59 T 36.2 O2 98 RR 18. @ 0025 (00:25 AM on 03/17/2025 BP 103/69 HR 58 T 36.1. @ 0036 (00:35 AM on 03/17/2025) Called physician exchange again to follow up on not receiving a call back from the doctor. @ 0115 (01:15 AM on 03/17/2025) .during this assessment resident appeared more lethargic (drowsy, decrease in consciousness that affects mental status) than usual, no response to sternal rub (painful stimulus to test consciousness), and no response to yes or no questions . CN made aware again. Resident's baseline-responses yes or no to questions by blinking. @ 0153 (01:53 AM on 03/17/2025) MD1 called the facility back .Dr stated to send the resident out (to ER). @ 0206 Called 911. @ 0218 BP 134/86 O2 98 HR 61 RR 18. @ 0220 Resident transferred . 03/16/2025, 11:58 PM - 03/17/2025: [NAME]-Night Shift: Neurological LOC (level of consciousness): Alert. The areas on the form for Oriented, and Pupils were not completed. Although vital signs were documented and taken on a schedule that is standard for post fall with potential head injury, the nursing staff failed to do full neurological assessments, which should include LOC, and pupillary reaction. LOC for R1 would be if he could respond the way he usually did, blinking eyes to yes and no questions, smiling, response to suction and any sensation he may have (baseline could not be determined by documentation). Based on nursing notes, there was a significant change in condition at 01:15 AM, when R1 was not responsive to sternal rub and lethargic. With calls out to notify MD1, with no response, the nursing staff should have had the skill set to identify this as an emergency condition, called 911 and transferred R1 to the hospital. 4) Reviewed Nursing documentation from the time R1 returned to the facility prior to being transferred to ER for the second time. 03/17/2025 entered at 07:14 PM, Progress note: Resident back from QMC (hospital) @ 1210 (PM) .Noted L (left) cheek with redness and slightly swollen. Resident is less responsive, compared to his baseline. Does not blink eyes to questions asked. (Use to blink when talked to and if it's 2 x blink it means yes). Bilateral eyes constantly moving left to right or right to left side only. Able to clean his mouth using yankauer (suction tool) without difficulty. (Used to bite yankauer when doing oral care and smile at staff). Tongue constantly moving and deviated to the left. There is no evidence R1's physician was contacted to report R1's neuro status on return to the facility, which was not his baseline. 03/17/2025, 11:50 PM-03/18/2025 [NAME]-Night Shift: Neurological LOC: Alert. The areas on the form Oriented and Pupils, were not completed. Nursing note: .complete neuro (neurological) checks and vitals q 4 hr (every four hours). No blinking response to yes or no questions, bilateral eye movement continues to move left to right. Although complete neuro checks was documented to be done in the nursing note above, the entries were not found. 03/18/2025, 07:49 PM (Late Entry), Day shift Progress Note: .Received bedside report from NOC (night) RN. Per NOC RN Vitals are stable, but he seems lethargic and not at his baseline.RN called patient by their name and no response. RN opened patient's eyelid and flash a light to pupils. Non reactive and constricted, .RN made jokes to make the patient smile. Patient blinks as a form of communication.Patient was non-reactive, no smile and bilateral eyes were in horizontal nystagmus (involuntary rapid eye movements). RN assess eyes again and no change.Frequent checks made on patient through the night.No further neuro signs noted. Patient is nonreactive and eyes remain horizontal nystagmus.no smiling. 03/18/2025, 10:06 PM-03/19/2025 [NAME]-Night Shift: The neurological area on the form was not completed. Nursing Note: Pt (R1) was sent out to QMC (hospital) at 21:43 (09:43 PM). Pt had fall 3/17 (actual date was 03/16/2025), was sent to the ER for assessment, but was sent back to KM (facility) due to no abnormal findings. Pt's baseline is responsive. However, at BSSR (bedside shift report) and during med pass, pt noted to have a significant difference. Pt noted to also have pin-point pupils and increased lethargy. See Charge RN progress notes for further details . 03/18/2025, 10:26 PM, SBAR (Situation, Background, Assessment, Recommendations) report documented by NOC Charge RN: S: resident s/p (post) fall on 3/16, hx of TBI and VP shunt. Noted AMS upon starting shift and eye abnormalities. Concern that Resident needs reevaluation in ED for abnormal findings not consistent with baseline or expectations after a fall. B: resident p/fall on 3/16, returned to facility on 3/17 after having CT (cat scan) that showed no abnormal results. PMH (Past medical history) hx of TBI with VP shunt (tube that drains excess cerebrospinal fluid into abdomen), convulsions, quadriplegia. At baseline resident is responsive, laughs, tracks with eyes, no nystagmus, and blinks for yes and not blinking for no. A: resident with AMS, difficulty to arouse, lethargic, pupils pinpoint, nonreactive and fixed, noted to have constant horizontal nystagmus that is uncontrolled, unable to track, appears to have decreased facial muscle tone blinking. After awaking resident, noted that he was attempting to answer questions, however d/t (due to) facial tone he could not close his eyes while blinking. S: contacted MD1 (Provider) @ 2050 (08:50 PM), received orders to send resident to ER for revaluation.called 911 at 2120 (09:20 PM) and resident transferred .at 2145 (09:42 PM). In addition to the notes above, the staff initiated the Neurological Assessment Flow Sheet when R1 returned to facility 03/17/2025 at 12:10 PM. The flow sheet included instructions and area to document Level of Consciousness (LOC), Pupil Response, Motor functions-Hand grasps, Extremities, Pain Response and Vitals. It directed staff to use the Observation Column to note the presence or absence of specific resident conditions. Reviewed the flow sheet, which included the following: 03/17/2025 at 12:10 PM: Vital signs documented. 03/17/2025 at 01:47 PM: Vital signs documented. 03/17/2025 at 01:47 PM: Vital signs documented. 03/17/2025 at 01:47 PM: Vital signs documented. 03/17/2025 at 01:47 PM: Vital signs documented. 03/18/2025 at 12:00 PM: Vital signs documented. 03/18/2025 at 04:07 PM: Vital signs documented. There were no neurological assessments of LOC, Pupil response, or observations documented on this flowsheet. The Neurological assessment documented on return to the facility (03/17/2025, day shift) indicated R1 was not at his baseline. Assigned nursing staff night shift ( 03/17/2025 to 03/18/2025) and day shift 03/18/2025, continued to document he was not at baseline. In addition, the neuro exams did not consistently include pupillary response. It was not until 03/18/2025 at 08:50 PM, over 24 hours later, that the physician was notified for order to transfer to ER for reevaluation. 5) Review of Falls - Clinical Protocol policy and procedure, last revised March 2018. The policy included the following: .the nurse shall assess and document/report the following: .Change in condition or level of consciousness; . Neurological status; . The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved .signs of subdural hematoma or other intracranial bleeding could occur up to several weeks after a fall. This policy did not include any specifics as to how or when to do neuro checks. Reviewed the facility policy titled Neurological Assessment (Routine), last revised October 2023. The purpose statement was . to provide guidelines for conducting a routine neurological assessment (neuro checks). Equipment listed that was necessary when performing this procedure included a flashlight and documentation tool. The policy included: 1. Routine neurological assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury. 2. Routine neurological exams include assessing: a. mental status and level of consciousness; b. pupillary response; . Neurological Assessment/Evaluation included: 1. Mental Status: a. Determine the level of consciousness and alertness. b. Determine orientation to time, place and person. 2. Pupillary Response: a. Test both pupils to ensure they are equally reactive to light and accommodation. b. diameter of the pupils usually ranges from two to five millimeters, c. Test pupillary reaction to light. (1) Dim the lights of the room before performing this test (2) Using a penlight, approach the patient from the side. (3) Shine the penlight on one pupil. Observe the response of the lighted pupil. It should quickly constrict (direct reaction). The other pupil should constrict (consensual reaction). (4) Repeat with the other pupil. The policy included the expectation to document all assessment data obtained in the medical record, and Notify the physician of any changes in a residents neurological status. This policy was not specific regarding the frequency of neuro checks On 06/17/25, between 07:30 AM and 04:30 PM, multiple confidential interviews were done with facility staff. During an interview with Anonymous Staff Member (ASM)9, he/she reported that they had noticed after a review of the facility's policies and procedures that there was nothing found regarding conducting a neurological (neuro) assessment after a fall. Reviewed the facility policy titled Change in a Resident's Condition or Status, last revised February 2021. The policy statement was Our facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. The policy included: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an) a. accident or incident involving .; d. significant change in the resident's physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center; . 2. A significant change of condition is major decline . in the resident's condition status that: a. will not normally resolve itself without intervention . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (structured report for physician communication; Situation, Background, Assessment and Recommendation) Communication form. 7. The nurse will record in the resident's medical record information relative to changes in the resident's medical .condition or status. 6) On 06/16/2025 at 03:45 PM, interviewed ASM7. She said when R1 arrived back from the ER on [DATE], she assessed him right away. She said he had redness on left cheek, opened his eyes, but was not blinking. She said she reported it to the CN because he was not at baseline and worried about his eyes going left to right. ASM7 said she did not personally notify the physician, and did not know if the CN did. She said she used the neuro flow sheet and reported her concerns to the noc nurse at shift change. On 06/17/2025 at 07:47 AM, interviewed the ASM8, who was on at the time of the fall. Discussed the CN role and she said if something is going on, the staff will notify the CN, and they would call the doctor if needed. She went on to say they were trialing something new, and trying to have the assigned nurse be more involved and the CN would assist. The CN said she was in the next room and heard the fall, so was there quickly. She said from her recall, three staff moved R1 back to the bed. Inquired who assessed R1 when he was on the ground, before moving him, and she said she was not sure, but thought it was the nurse. She said R1 could not grasp (hand grasp is part of neuro check), so a neuro check for him would be if he can blink and checking his pupils. When asked if they did this prior to moving him, she said I think we never did. When asked if nursing could call 911, if there was an emergency, and then notify the physician after, she said yes. On 06/19/2025 at approximately 09:30 AM, conducted a telephone interview with ASM6, who entered R1's room after he was already in bed, about 15 minutes after the fall. He/she said the assigned Nurse was just starting the assessment, and he/she was unsure how much experience the Nurse had with neuro assessments, and a second set of eyes would be good who knows his (R1's) normal baseline. ASM6 said R1 had changes at that time, and his eyes were fluttering back and forth. He/she went on to say normally, R1 responds to jokes, bites down on the suction tube and you have to tell him to stop. He will look at you, and responds to your voice. ASM6 said R1 was not responding the way he normally was, his playfulness was gone. When they did the neuro check, they turned off the lights and checked pupils. When asked how they checked pupils, he/she said they used the cell phone flashlight. ASM6 said they looked for a form to document the ongoing neuro checks, but could not find it. On 06/17/2025, conducted a telephone interview with ASM9, who said on 03/18/2025 when he/she received report from the day shift, they reported some things about R1's behavior, which made him/her think R1 would probably need to be sent to the ER. ASM9 asked the day shift if they called the doctor, and reported his condition, but they had not. He/she said if the doctor was not called, he would assume R1 came back from the hospital at his baseline, which was not the case. ASM9 assessed R1, and said he looked panicky and fearful. He/she went on to say he was trying to answer, his pupils were moving crazy back and forth, and he wasn't blinking. ASM9 said it was like he had loss of muscle tone in his face, with one side reacting less than other side, trying to blink, but couldn't. He/she said R1 was very hard to wakeup. After the assessment, he/she called the physician and then sent him to the ER. ASM9 said he/she documented R1's baseline on the transfer form, and the ER doctor called about 03:00 AM, and wanted additional information regarding his usual behavior. He/she was unsure if the ER was aware of R1's baseline on the first visit. On 06/17/25 at 11:23 AM during a concurrent interview and review of R1's neuro assessments following his fall with the Director of Nursing (DON), DON agreed that at a minimum, nursing staff should have documented level of consciousness (LOC) and pupil response in addition to the vital signs that were documented. On 06/17/25 at 02:29 PM, an interview was done with the DON. When asked for the competency checklist for Certified Nurse Aide (CNA)1 (the staff member responsible for leaving the bed/safety rail down as she provided perineal care to R1 by herself, resulting in him falling out of bed), DON reported that he had been unable to locate a skills/competency checklist but was looking further into it. On 06/18/25 at 08:32 AM, an interview was done with the DON, at which time he confirmed he did not have a skills/competency checklist that was completed for CNA1. He agreed that it should have been done. On 06/18/25, during a confidential interview with ASM11, when asked if there had been any training on neuro assessments since R1's fall (when to conduct them, how to conduct a neuro assessment properly, how often to conduct them), he/she responded that he/she was not aware of any training on neuro assessments. When asked if he/she had a penlight to conduct a neuro assessment if he/she needed to, ASM11 responded that he/she did not have a penlight, and to his/her knowledge, the facility did not have any penlights available (for example, in the med cart). Concurrent inspection of the facility medication and treatments carts confirmed no penlights available to assess pupil response for a neuro assessment. 7) On 06/18/2025 at approximately 08:15 AM., observed the layout of R1's room with ASM8. R1's mechanism of injury was a fall from bed. The CNA was in the room, but could not see if he struck his head. There was redness observed on his R1's upper forehead, and he had a history of brain surgery with missing bone, and a shunt. There was high likelihood he struck his head on something. The standard of care post fall, would be to do a thorough head-to-toe assessment, full set of vitals and a neurological assessment, prior to moving him. The initial assessment would determine if he could be moved safely, or if EMS should be called (American Association of Post-Acute Care Nursing, Post-Fall Assessments, August 2021; American Nurse Journal 2023, The VIP treatment: A comprehensive post-fall assessment guideline). On 06/18/25 at 09:50 observations were done at the Nurses' Station. Review of the In-Service binder revealed no in-services had been conducted on how to perform a neuro assessment following R1's incident. 8) The facility documentation and interviews did not provide evidence that; 1) staff were knowledgeable of the importance to complete an thorough physical and neurological assessment, to determine if R1 could be moved safely; 2) the nursing staff understood what a complete neurological assessments was (i.e. pupils, eye movement, change from baseline), and how often they should be done, 3) the nursing staff understood the importance of timely transfer when neurological changes are noted, and 4) there was a structured approach to neurological assessments.