Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family interview, physician interview, staff interviews, and facility policy review, the facility failed to provide appropriate assessment and interventions for 1 out of 3 residents (Resident #158). Clinical record review revealed on [DATE] at 9:30 p.m., Resident #158 fell and sustained a laceration to her head with a significant amount of blood loss. The facility staff failed to immediately call 911, call the physician, call the family, or conduct neurological assessments as per policy. The facility staff moved the resident to the shower and then to bed. Upon arrival of the next shift 9 hours later, the facility sent the resident to the emergency room (ER) where the resident was assessed to have fractures of the humerus and femur. The failure of assessing the resident properly and seeking immediate emergency treatment caused an Immediate Jeopardy (IJ) to the health and safety of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 11:00 a.m. The facility staff removed the Immediate Jeopardy on [DATE] by implementing the following actions: 1. Resident #158 was discharged from the facility on [DATE]. 2. The 24-hour Summary Reports will be reviewed from [DATE] through [DATE] to determine whether resident assessments and subsequent intervention were implemented for residents experiencing a change of condition. If additional residents are identified who did not receive adequate assessment or subsequent intervention, the residents will be reassessed, and the respective Physician's will be notified. Completion date: [DATE] 3. All Nurses will be educated on the facility Post-Fall Check List, Fall Prevention and Management Program Policy, Microlearning: Observation and Reporting (the educator will also include the incident in question as an ancillary case study to the Microlearning), and the Communication and Notification - Staff, Practitioner, and Resident Representative Policy. Completion date: [DATE]. For nurses who are not available for training by the designated completion date (e.g., on FMLA, PRN and at College, on PTO), they will not be allowed to work a shift until they receive this training. 4. The 24-hour summary report will be reviewed daily by the interdisciplinary team (IDT) to ensure all resident changes of condition are identified timely and appropriate assessment and intervention occur. Completion date: [DATE]. 5. The Clinical Administrator or designee will attend the IDT meetings two times per week x 6 weeks to ensure the 24-hour summary report reviews are occurring and to ensure all resident changes of condition are identified timely and appropriate assessment and intervention occur. Date monitoring will be initiated by (completion date): [DATE]. 6. The facility Policy: Fall Prevention and Management Program Policy with a modified date of [DATE] was reviewed on [DATE] and remains appropriate. 7. The facility Policy: Communication and Notification - Staff, Practitioners, and Resident Representatives Policy with a modified date of [DATE] was reviewed on [DATE] and remains appropriate. The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #158 revealed the following diagnosis; dementia, anxiety, depression, glaucoma, high blood pressure and kidney disease. The MDS recorded the resident's cognitive skills for daily decision making as moderately impaired and the resident required supervision with limited assistance of 1 person for bed mobility, toileting and personal hygiene. The MDS coded that the resident was able to ambulate independently with a walker. The Care Plan dated [DATE] directed staff to administer pain medication as ordered and to monitor for both verbal and nonverbal signs and symptoms of pain and discomfort. The care plan instructed staff to monitor for signs or symptoms of further mood decline and update the physician as needed. A Progress Note dated [DATE] at 9:45 PM revealed Resident #158 yelled for help, found on the floor outside of the bathroom, laying on her right side, complained of pain all over, range of motion (ROM) and neurological checks were normal, and therefore the resident was moved from the floor with the assistance of 2 staff. The entry recorded an injury described as a 3 centimeter (cm) by 5 cm hematoma (localized bleeding, bruise) and 3 cm by 1 cm skin tear to the right eye. The entry documented the notification of the On-Call Registered Nurse (RN) Staff A, and a fax to Staff H, Physician, and that the Power of Attorney (POA) would be notified in the morning. The document titled Resident Occurrence dated [DATE] revealed: a. Resident #158 yelling, found outside bathroom door. b. Last observed in the dining room at 9:15 PM. c. Resident walking, no walker. d. Prevention from occurring again: frequent checks. e. Position of resident, on right side with gripper socks on, not wearing glasses. f. The floor was shiny. g. Signature Staff B, RN; Staff G, Certified Nursing Assistant (CNA); and Staff D, CNA. The document titled Neuro Check Flow Sheet for Resident #158 revealed: a. On [DATE] at 9:45 PM, the resident alert, neuro check normal, pupils equal, reactive, brisk, with vital signs (VS) recorded as blood pressure (BP) 146/68 pulse (P) 68 and no change from baseline assessment. The entry lacked a pain assessment. b. On [DATE] at 10:00 PM, the resident alert, neuro check normal, pupils equal, reactive, brisk, with VS: BP 165/71 P 64, and no change from baseline assessment. The entry lacked documentation of a pain assessment. c. On [DATE] at 11:00 PM, the resident alert, neuro checks normal, pupils equal, reactive, brisk, with VS: BP 154/73, P 63, and no change from baseline assessment. The entry lacked documentation of a pain assessment. d. On [DATE] at 12:00 AM, the resident slept with VS: BP 148/54, P 74, and no change in baseline assessment. The entry lacked documentation of a comprehensive neuro check, pupil assessment, or pain assessment. e. On [DATE] at 2:00 AM, the resident was sleeping. The entry lacked documentation of a comprehensive neuro check, pupil assessment, measurement of VS, and pain assessments. f. On [DATE] at 4:00 AM, the resident slept with VS: BP 168/86, P 63, and no change in the baseline assessment. The entry lacked documentation of comprehensive neuro check, pupil assessment, and pain assessments. g. On [DATE] at 8:00 AM, the resident was sent to the hospital. h. Signature Staff B, RN The document titled Falls Follow up Form dated [DATE] at 9:45 PM recorded the following: a. Identified Resident #158. b. Vital Signs BP 146/68, Pulse 68, Respirations 18, Temperature 97.8, Oxygen Saturation 94%. c. The document lacked the following assessments: -Change of condition. -Sensory impairments. -Change in elimination. -Gait balance impairment: ROM, change in the ability to transfer. -Change in activity pattern: Sleep. -Pain. d. Analysis and Summary of causal factors: -Coming from the bathroom. -Not using a walker. e. Interventions: -Frequent checks. -Reminder to use the walker. f. Signature by Staff B, RN. A Facility Fax dated [DATE] at 10:55 PM revealed: a. Resident #158 was found on the floor. b. Vital signs Blood Pressure 146/68 Pulse 60. c. Hematoma and skin tear to the right eye. d. ROM and neurological checks are normal. e. Pain all over. f. Physician signature received on [DATE]. The Medication Administration Record (MAR) dated [DATE] for Resident #158 revealed: a. Acetaminophen (a.k.a. Tylenol) 325 milligrams (mg) to be administered four times a day. b. Acetaminophen administered on [DATE] four times, the last dose at bedtime. c. Fentanyl (narcotic pain medication) 12 micrograms/hour 72 hour patch. d. Fentanyl patch last applied on [DATE]. e. MAR lacked an order for as needed (PRN) pain medication. f. MAR lacked documentation of a Standing Order pain medication administered on [DATE] - [DATE]. A Change of Condition Note dated [DATE] at 6:30 AM revealed Resident #158 complained of pain to the right upper extremity (RUE), refused to move the arm, and yelled out in pain when the nurse touched RUE. The documentation revealed Staff H, the POA, Staff A, and Emergency Medical Services (EMS) were notified and a report was called to the emergency room (ER) Nurse. Resident #158 was transferred to the local hospital at 6:47 AM. The Local Hospital ER Notes dated [DATE] at 7:10 AM revealed Resident #158 arrived via ambulance laying on her left side, unable to roll over onto her back, guarding her right arm, and she yelled no with a light touch to the deformity noted on the right humerus. The notes documented the resident's left lower extremity shortened and rotated, a laceration with dried blood present above her right eye, and diffuse bruising around the right orbit. The x-ray of the right shoulder revealed a displaced fracture of the right humerus and the x-ray of the right hip revealed a displaced right femur fracture; the resident was treated with oxygen and Dilaudid pain medication. A Progress Note dated [DATE] at 5:26 PM documented a phone call placed to the local hospital for an update on Resident #158 and the resident was diagnosed with a fractured right shoulder, fractured right hip, and required a higher level of care therefore transferred to a tertiary hospital. A Progress Note on [DATE] at 6:57 AM documented notification given to Staff H that Resident #158 admitted to the tertiary hospital. A Progress Note on [DATE] at 11:51 AM revealed Staff H acknowledged the fax received in regards to Resident #158's fall. A Facility Fax dated [DATE] at 5:49 AM revealed: a. Resident #158 was transferred to the local hospital for an evaluation. b. Resident #158 was subsequently transferred to tertiary hospital and admitted for hip and shoulder fractures. c. Physician signature received on [DATE]. A Hospital Report on [DATE] at 1:58 PM revealed: a. Resident #158 was admitted due to uncontrolled pain. b. Significant bruising to the right eye area, laceration near the right eye, right femur and right humeral head fracture. c. Resident #158 had a history of dementia and prior stroke and was on Plavix (blood thinner). d. Recommendation to the family was to focus on comfort care with Hospice support for pain management. e. Resident #158 had significant bleeding from head, two staff reportedly got her off the floor, showered her and placed her in the bed for the night without calling the physician or family. A Progress Note on [DATE] at 11:50 AM revealed Resident #158 returned from the hospital via ambulance, drowsy but responsive to pain. The entry recorded the resident had a fracture to right humeral head and femoral neck, multiple bruises to face and right arm due to recent a fall on [DATE]. The entry documented the resident admitted to Hospice care and treated with Oxycodone (narcotic pain medication) 2.25 milliliters (ml) for the pain. A Progress Note on [DATE] at 1:30 PM revealed Resident #158 passed away with family at bedside. During an interview on [DATE] at 1:59 PM, Staff J, CNA stated that after a normal fall, the staff use the walkie to call the nurse who does the evaluation, measures vitals, and the staff would use a sling and Hoyer (mechanical lift) to get the resident up unless the resident can get up on their own. Staff J stated if a resident could stand, then they would get up themselves. During an interview on [DATE] at 2:16 PM, Staff B, RN stated Resident #158 was independent with ambulation. Staff B reported the resident fell close to the shift change in the bathroom, cut her eyebrow, it was not actively bleeding, but the resident had blood on the floor, her hands and her legs. Staff B stated the staff cleaned up the blood, assessed her neuro's, range of motion, vital signs and Staff B told the staff to get the resident up to a shower chair. Staff B stated the staff stood the resident, pivoted her to the shower chair, and washed off the blood. Staff B stated she completed the fall paperwork and sent the incident paperwork to Staff A. Staff B stated the staff dressed the resident and put her to bed. Staff B stated the resident was in pain but could not tell Staff B where the pain was located. Staff B said at 4:30 AM or 5:00 AM the staff tried to move the resident and the resident's arm hurt. Staff B stated she didn't remember notifying the doctor but she did send a fax to him. Staff B stated Resident #158 was bleeding and she applied first aid. During a family interview on [DATE] at 2:33 PM, the POA stated she was not notified on the evening Resident #158 fell. The POA stated the staff said the resident fell around 9:00 PM or 10:00 PM and they didn't call her until 6:30 AM to ask if she could go to the hospital. The POA stated the staff reported they got the resident up and put her in the shower due to having blood everywhere. The POA voiced the prognosis and the resident's ability to do therapy was poor. The POA stated they offered comfort care so she agreed to that and the resident returned to the facility where she died on [DATE]. The POA voiced that the facility left the resident there to suffer in pain all that night with a fractured hip and shoulder. The POA stated the resident resided at the facility for 8 years and when the staff said they didn't want to bother her in the middle of the night, she asked the nurse when 9:30 PM considered the middle of the night, but the staff would not answer her. In an interview on [DATE] at 3:53 PM, Staff K, RN stated when a resident fell the nursing staff followed the fall protocol, obtained vital signs, performed an assessment of the extremities and pain, and charted observations to include the position of the resident, the wheelchair or walker, and what the resident wore. Staff K stated if a resident could stand, they moved them. Staff K stated the protocol was to call the doctor and hospital intervention if needed; fax the physician if no visible injuries. Staff K stated on [DATE] she arrived at 6 AM and during the nurse report, the night nurse stated Resident #158 fell in the Memory Care Unit and bumped her head. Staff K stated that Staff B, RN claimed the staff found the resident and there was so much blood that the staff showered the resident before they put her to bed. Staff K stated Staff B reported that Resident #158 had a head injury of a skin tear but was not sent to the hospital. Staff K stated the resident was really in so much pain, it could be seen on her face and when they moved the resident ' s arm she shouted in pain. Staff K stated Staff B then called the On-Call nurse, the doctor and family at 6:30 AM. Staff K stated the POA called back and asked her if the staff normally showered someone after a fall. Staff K said she responded that the night nurse said they had to because there was so much blood they couldn't find where it was coming from. In an interview on [DATE] at 8:05 PM, Staff G, CNA stated she found Resident #158 on the floor on [DATE] at 9:30 PM. Staff G voiced she would not forget it because it was traumatic for her. Staff G stated Staff D, CNA heard Resident #158 called out and she found the resident lying on the floor just inside her bathroom, in her bedroom, on her right side in the fetal position. Staff G reported the resident was not lying still and she moved around in the blood. Staff G recalled blood being present on the floor, up the wall, in the resident ' s hair, and on the left side of her head, hands and legs. Staff G stated she called the nurse with the walkie and put a pillow under the resident ' s head. Staff G reported there was so much blood that she started wiping the resident ' s hands off with a washcloth to see where it was coming from. Staff G commented that the resident ' s left side of her face and hair were red. Staff G stated Staff B, RN came in, took the vital signs and instructed her to get Resident #158 in the shower to wash away the blood. Staff G said the resident ' s pajamas were soaked in blood. Staff G stated Staff B assisted to stand Resident #158 up, pivoted her into a shower chair, washed her off, then started to dress the resident. Staff G recalled Resident #158 said it hurt and told them not to push when they applied the gripper socks and pants. Staff G stated Staff D helped to push the shower chair next to the bed, they stood Resident #158 and pulled up her pants, pivoted her and put her into the bed. Staff G stated she asked Staff B if she thought they should send the resident out due to the resident losing so much blood but Staff B did not. During an interview on [DATE] at 7:50 AM, Staff A, RN Clinical Administrator stated she did not know about the fall until the morning of [DATE] at 6:30 AM and she said to send the resident to the hospital. Staff A stated the staff knew they could call 24/7 and the expectation was to call with a fall. Staff A reported they did not investigate the fall and they did not interview the staff. Staff A stated that Resident #158 was ambulatory and therefore no self report was made to the state. Staff A stated the fall happened during her first week at the facility. During an interview on [DATE] at 9:05 AM, Staff H, Physician responded if anyone found a resident on the floor, he would expect the staff to look for any visible wounds, assess for pain in any extremity and if they had a visible head wound, there may be a hemorrhage so of course to call 911. Staff H stated the staff could call 24/7 to report a fall and receive orders for treatment. In a subsequent interview on [DATE] at 10:28 AM, Staff H, Physician stated a review of the call logs revealed that there was no call for a fall on Resident #158 and he did not remember receiving one. Staff H stated he found a fax dated [DATE] at 10:45 PM that documented Resident #158 was found on the floor on her right side, her range of motion and neuro's were normal, she had a hematoma and complained of pain all over. Staff H commented that looking at the fax, the staff should have called 911. Staff H stated another fax received on Monday [DATE] at 5:49 AM documented the resident transferred to the local hospital. Staff H said a 2nd fax received on [DATE] at 3:47 PM notified him of the resident's death, 2 hours after Resident #158 passed away. During an interview on [DATE] at 8:08 AM, Staff E, CNA reported working for the facility for 13 years. Staff E stated on [DATE] at 10:00 PM she received a report that Resident #158 fell and the other CNA's had showered her. Staff E recalled Resident #158 wore a nightgown and laid in bed shaking. Staff E said the resident didn't verbalize and she didn't even touch the resident that night as the resident laid at the head of the bed but had turned herself around with her head at the foot of the bed. Staff E voiced she didn't touch the resident, provide check and change care, or turn the resident because she didn't want to cause her any more pain. Staff E reported the resident laid in the fetal position in bed all night shaking. Staff E voiced the resident was shaking really badly and the resident did not shake normally and therefore Staff E was not comfortable with doing anything with the resident. Staff E recalled thinking why didn ' t they send her out. Staff E stated that Resident #158 remained at the facility as of 6 AM when her shift was complete. Staff E stated the Memory Care Unit was where she worked and Resident #158 normally slept all night and would get up when she needed to use the bathroom. During an interview on [DATE] at 11:00 AM, Staff B, RN stated Resident #158 was able to sit up, had full range of motion to her arms and legs, and no complaints of pain. Staff B said she wanted the resident cleaned up as she had dried blood in her hair, on her hands, and legs. Staff B stated she gave the instruction for the CNA's to get Resident #158 showered. Staff B said while she observed, the resident alternated cradling her arms in her lap. Staff B stated the CNA's put the residents arms in her gown, they wheeled the shower chair over to the bed and put the resident to bed onto her right side and covered her. Staff B said she completed another set of vital signs and neurological checks. Staff B reported when she returned an hour later the resident slept and she was sleeping every time Staff B went into her room. Staff B stated she had notified the On-Call Nurse, Staff A, with a text, who responded ok. Staff B said she continued neuros during the night and the resident ' s eye was bruised. Staff B stated Staff E called at midnight, reporting Resident #158 was experiencing pain. Staff B commented the resident didn't look like she was in distress, nothing unusual. Staff B stated that Staff E reported Resident #158 was moving around in her bed, laid toward her headboard and other times her head toward the foot board. Staff B administered an as needed (prn) Tylenol at midnight per the standing order. Staff B voiced she didn't document it as the stomach pain was normal for the resident. Staff B stated she did not notify the doctor in this case as there was a standing order. Staff B reported at 4:00 to 5:00 AM, the resident said ouch, don't touch her arm. Staff B stated she updated Staff A with a text at that time that she was working on sending the resident out for further evaluation. Staff B stated she made the decision to send the resident out. Staff B said she notified the POA at 4:00 -5:00 AM letting her know the resident fell the night before, cut above her eyebrow, they cleaned her up in the shower, completed neuro checks and she had a change. Staff B stated the resident didn't want to move her right arm so Staff B wanted to send the resident out if the POA was okay with it. Staff B stated she called the provider to get the order and called the ER at the local hospital to give a report. During an interview on [DATE] at 9:24 AM, Staff A, RN, Clinical Administrator stated she checked for a text from Staff B on the evening of [DATE] and she did not get a text or call. Staff A stated she did not get a call until [DATE] at 6:30 AM when she said to send Resident #158 to the hospital. During an interview on [DATE] at 2:30 PM, Staff L, Advanced Registered Nurse Practitioner (ARNP), stated she remembered receiving a call on [DATE] from the nurse asking permission to send the resident to the hospital. Staff L reported she was on call for the providers in that area and at the hospital emergency room (ER). Staff L stated the staff did not call the physician when Resident #158 fell at 9:00 PM on [DATE]. Staff L voiced the whole thing was not right as Staff B said they found the resident down, put her back to bed, and the resident didn't want to get up in the morning, so they needed permission to send her. Staff L stated the resident had a head injury, there was shortening of the resident's right leg and it was rotated outward, the resident guarded her right arm screaming if staff touched it, and they gave the resident nothing for her pain. Staff L stated the staff should have called the on-call provider at the time Resident #158 was found on the floor to seek treatment orders; the on-call providers take calls 24/7. The policy titled Fall Prevention and Management dated [DATE] revealed: a. The Clinical Administrator is responsible for assuring implementation of this policy. b. All staff are responsible for implementing the intent and directives contained within this policy. c. The Nurse will immediately evaluate the resident for any injury, change in status and/ or pain and will proceed with emergency procedures and interventions as indicated. d. Suspected head injury or possible significant injury or fracture: the resident is not to be moved until emergency personnel have arrived unless it is determined that the resident is at risk for injuring self further or is at risk for further injury if they are not moved. e. The Nurse will notify 911, the primary physician and/or Nurse Practitioner (NP) and the RN in charge as indicated based on the initial evaluation and the resident care plan. f. The Staff Nurse will complete the resident Occurrence Report and notify the physician and responsible party. g. Minor Head Trauma or Unwitnessed Fall where the resident is not able to state if they hit their head 1. Determine vital signs including orthostatic blood pressures. 2. Determine circumstances leading to the fall and interventions. 3. Perform Neuro Checks: a. Day 1: i. Every 15 minutes x 2 ii. Every hour x 2 iii. Every 2 hours x 2 iv. Every 4 hours x 2 b. Days 2 and 3: i. Every shift c. Alert the Physician or NP with any changes. h. An entry into the medical record will be completed to include: patient appearance at time of discovery, patient response to event, evidence of injury, location, medical provider notification, responsible party notification, nursing actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family interview, staff interviews, and facility policy review, the facility failed to provide appropriate pain management for 1 out of 3 residents (Resident #158). Clinical record review revealed on [DATE] at 9:30 p.m., Resident #158 fell and sustained a laceration to her head with a significant amount of blood loss. The facility staff moved the resident to the shower and then to bed and the resident reported pain that was not treated. Upon arrival of the next shift 9 hours later, the facility sent the resident to the emergency room (ER) where the resident was assessed to have fractures of the humerus and femur and immediately treated for pain; the resident admitting diagnoses included uncontrolled pain. The failure created an immediate jeopardy to the health and safety of the resident. The facility reported a census of 57 residents. After a QA Review, the State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 12:30 p.m. related to pain management. The facility staff removed the Immediate Jeopardy on [DATE] by implementing the following actions: 1. Resident #158 was discharged from the facility on [DATE]. 2. The staff nurse in question was separated from the resident and put on indefinite suspension beginning [DATE] pending outcome of Dependent Adult Abuse investigation. 3. All clinical staff educated on the Pain Assessment and Management Policy. Staff education occurred on [DATE], [DATE], and [DATE]. Any staff who were PRN (casual status), student status, leave status, or who otherwise did not work on a routine basis were allowed to work the floor until after the time they had been able to be educated on the Pain Assessment and Management Policy. 4. The facility Pain Assessment and Management Policy was reviewed on [DATE] with no subsequent changes. 5. The Clinical Administrator, Care Center Administrator or designee will interview 25% of care center residents per week x 4 weeks to determine if licensed staff are responsive to resident pain. This will include staff and family interviews for residents in the CCDI household. Any identified issues will be referred to the subsequent QAPI meeting. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #158 revealed the following diagnosis; dementia, anxiety, depression, glaucoma, high blood pressure and kidney disease. The MDS recorded the resident's cognitive skills for daily decision making as moderately impaired and the resident required supervision with limited assistance of 1 person for bed mobility, toileting and personal hygiene. The MDS coded that the resident was able to ambulate independently with a walker. The Care Plan dated [DATE] directed staff to administer pain medication as ordered and to monitor for both verbal and nonverbal signs and symptoms of pain and discomfort. The care plan instructed staff to monitor for signs or symptoms of further mood decline and update the physician as needed. A Progress Note dated [DATE] at 9:45 PM revealed Resident #158 yelled for help, found on the floor outside of the bathroom, laying on her right side, complained of pain all over, range of motion (ROM) and neurological checks were normal, and therefore the resident was moved from the floor with the assistance of 2 staff. The entry recorded an injury described as a 3 centimeter (cm) by 5 cm hematoma (localized bleeding, bruise) and 3 cm by 1 cm skin tear to the right eye. The entry documented the notification of the On-Call Registered Nurse (RN) Staff A, and a fax to Staff H, Physician, and that the Power of Attorney (POA) would be notified in the morning. The document titled Resident Occurrence dated [DATE] revealed: a. Resident #158 yelling, found outside bathroom door. b. Last observed in the dining room at 9:15 PM. c. Resident walking, no walker. d. Prevention from occurring again: frequent checks. e. Position of resident, on right side with gripper socks on, not wearing glasses. f. The floor was shiny. g. Signature Staff B, RN; Staff G, Certified Nursing Assistant (CNA); and Staff D, CNA. The document titled Neuro Check Flow Sheet for Resident #158 revealed: a. On [DATE] at 9:45 PM, the resident alert, neuro check normal, pupils equal, reactive, brisk, with vital signs (VS) recorded as blood pressure (BP) 146/68 pulse (P) 68 and no change from baseline assessment. The entry lacked a pain assessment. b. On [DATE] at 10:00 PM, the resident alert, neuro check normal, pupils equal, reactive, brisk, with VS: BP 165/71 P 64, and no change from baseline assessment. The entry lacked documentation of a pain assessment. c. On [DATE] at 11:00 PM, the resident alert, neuro checks normal, pupils equal, reactive, brisk, with VS: BP 154/73, P 63, and no change from baseline assessment. The entry lacked documentation of a pain assessment. d. On [DATE] at 12:00 AM, the resident slept with VS: BP 148/54, P 74, and no change in baseline assessment. The entry lacked documentation of a comprehensive neuro check, pupil assessment, or pain assessment. e. On [DATE] at 2:00 AM, the resident was sleeping. The entry lacked documentation of a comprehensive neuro check, pupil assessment, measurement of VS, and pain assessments. f. On [DATE] at 4:00 AM, the resident slept with VS: BP 168/86, P 63, and no change in the baseline assessment. The entry lacked documentation of comprehensive neuro check, pupil assessment, and pain assessments. g. On [DATE] at 8:00 AM, the resident was sent to the hospital. h. Signature Staff B, RN The document titled Falls Follow up Form dated [DATE] at 9:45 PM recorded the following: a. Identified Resident #158. b. Vital Signs BP 146/68, Pulse 68, Respirations 18, Temperature 97.8, Oxygen Saturation 94%. c. The document lacked the following assessments: -Change of condition. -Sensory impairments. -Change in elimination. -Gait balance impairment: ROM, change in the ability to transfer. -Change in activity pattern: Sleep. -Pain. d. Analysis and Summary of causal factors: -Coming from the bathroom. -Not using a walker. e. Interventions: -Frequent checks. -Reminder to use the walker. f. Signature by Staff B, RN. A Facility Fax dated [DATE] at 10:55 PM revealed: a. Resident #158 was found on the floor. b. Vital signs Blood Pressure 146/68 Pulse 60. c. Hematoma and skin tear to the right eye. d. ROM and neurological checks are normal. e. Pain all over. f. Physician signature received on [DATE]. The Medication Administration Record (MAR) dated [DATE] for Resident #158 revealed: a. Acetaminophen (a.k.a. Tylenol) 325 milligrams (mg) to be administered four times a day. b. Acetaminophen administered on [DATE] four times, the last dose at bedtime. c. Fentanyl (narcotic pain medication) 12 micrograms/hour 72 hour patch. d. Fentanyl patch last applied on [DATE]. e. MAR lacked an order for as needed (PRN) pain medication. f. MAR lacked documentation of a Standing Order pain medication administered on [DATE] - [DATE]. A Change of Condition Note dated [DATE] at 6:30 AM revealed Resident #158 complained of pain to the right upper extremity (RUE), refused to move the arm, and yelled out in pain when the nurse touched RUE. The documentation revealed Staff H, the POA, Staff A, and Emergency Medical Services (EMS) were notified and a report was called to the emergency room (ER) Nurse. Resident #158 was transferred to the local hospital at 6:47 AM. The Local Hospital ER Notes dated [DATE] at 7:10 AM revealed Resident #158 arrived via ambulance laying on her left side, unable to roll over onto her back, guarding her right arm, and she yelled no with a light touch to the deformity noted on the right humerus. The notes documented the resident's left lower extremity shortened and rotated, a laceration with dried blood present above her right eye, and diffuse bruising around the right orbit. The x-ray of the right shoulder revealed a displaced fracture of the right humerus and the x-ray of the right hip revealed a displaced right femur fracture; the resident was treated with oxygen and Dilaudid pain medication. A Progress Note dated [DATE] at 5:26 PM documented a phone call placed to the local hospital for an update on Resident #158 and the resident was diagnosed with a fractured right shoulder, fractured right hip, and required a higher level of care therefore transferred to a tertiary hospital. A Progress Note on [DATE] at 6:57 AM documented notification given to Staff H that Resident #158 admitted to the tertiary hospital. A Progress Note on [DATE] at 11:51 AM revealed Staff H acknowledged the fax received in regards to Resident #158's fall. A Facility Fax dated [DATE] at 5:49 AM revealed: a. Resident #158 was transferred to the local hospital for an evaluation. b. Resident #158 was subsequently transferred to tertiary hospital and admitted for hip and shoulder fractures. c. Physician signature received on [DATE]. A Hospital Report on [DATE] at 1:58 PM revealed: a. Resident #158 was admitted due to uncontrolled pain. b. Significant bruising to the right eye area, laceration near the right eye, right femur and right humeral head fracture. c. Resident #158 had a history of dementia and prior stroke and was on Plavix (blood thinner). d. Recommendation to the family was to focus on comfort care with Hospice support for pain management. e. Resident #158 had significant bleeding from head, two staff reportedly got her off the floor, showered her and placed her in the bed for the night without calling the physician or family. A Progress Note on [DATE] at 11:50 AM revealed Resident #158 returned from the hospital via ambulance, drowsy but responsive to pain. The entry recorded the resident had a fracture to right humeral head and femoral neck, multiple bruises to face and right arm due to recent a fall on [DATE]. The entry documented the resident admitted to Hospice care and treated with Oxycodone (narcotic pain medication) 2.25 milliliters (ml) for the pain. A Progress Note on [DATE] at 1:30 PM revealed Resident #158 passed away with family at bedside. During an interview on [DATE] at 2:16 PM, Staff B, RN stated Resident #158 was independent with ambulation. Staff B reported the resident fell close to the shift change in the bathroom, cut her eyebrow, it was not actively bleeding, but the resident had blood on the floor, her hands and her legs. Staff B stated the staff cleaned up the blood, assessed her neuro's, range of motion, vital signs and Staff B told the staff to get the resident up to a shower chair. Staff B stated the staff stood the resident, pivoted her to the shower chair, and washed off the blood. Staff B stated she completed the fall paperwork and sent the incident paperwork to Staff A. Staff B stated the staff dressed the resident and put her to bed. Staff B stated the resident was in pain but could not tell Staff B where the pain was located. Staff B said at 4:30 AM or 5:00 AM the staff tried to move the resident and the resident's arm hurt. Staff B stated she didn't remember notifying the doctor but she did send a fax to him. Staff B stated Resident #158 was bleeding and she applied first aid. During a family interview on [DATE] at 2:33 PM, the POA stated she was not notified on the evening Resident #158 fell. The POA stated the staff said the resident fell around 9:00 PM or 10:00 PM and they didn't call her until 6:30 AM to ask if she could go to the hospital. The POA stated the staff reported they got the resident up and put her in the shower due to having blood everywhere. The POA voiced the prognosis and the resident's ability to do therapy was poor. The POA stated they offered comfort care so she agreed to that and the resident returned to the facility where she died on [DATE]. The POA voiced that the facility left the resident there to suffer in pain all that night with a fractured hip and shoulder. The POA stated the resident resided at the facility for 8 years and when the staff said they didn't want to bother her in the middle of the night, she asked the nurse when 9:30 PM considered the middle of the night, but the staff would not answer her. In an interview on [DATE] at 3:53 PM, Staff K, RN stated when a resident fell the nursing staff followed the fall protocol, obtained vital signs, performed an assessment of the extremities and pain, and charted observations to include the position of the resident, the wheelchair or walker, and what the resident wore. Staff K stated if a resident could stand, they moved them. Staff K stated the protocol was to call the doctor and hospital intervention if needed; fax the physician if no visible injuries. Staff K stated on [DATE] she arrived at 6 AM and during the nurse report, the night nurse stated Resident #158 fell in the Memory Care Unit and bumped her head. Staff K stated that Staff B, RN claimed the staff found the resident and there was so much blood that the staff showered the resident before they put her to bed. Staff K stated Staff B reported that Resident #158 had a head injury of a skin tear but was not sent to the hospital. Staff K stated the resident was really in so much pain, it could be seen on her face and when they moved the resident ' s arm she shouted in pain. Staff K stated Staff B then called the On-Call nurse, the doctor and family at 6:30 AM. In an interview on [DATE] at 8:05 PM, Staff G, CNA stated she found Resident #158 on the floor on [DATE] at 9:30 PM. Staff G voiced she would not forget it because it was traumatic for her. Staff G stated Staff D, CNA heard Resident #158 called out and she found the resident lying on the floor just inside her bathroom, in her bedroom, on her right side in the fetal position. Staff G reported the resident was not lying still and she moved around in the blood. Staff G recalled blood being present on the floor, up the wall, in the resident ' s hair, and on the left side of her head, hands and legs. Staff G stated she called the nurse with the walkie and put a pillow under the resident ' s head. Staff G reported there was so much blood that she started wiping the resident ' s hands off with a washcloth to see where it was coming from. Staff G commented that the resident ' s left side of her face and hair were red. Staff G stated Staff B, RN came in, took the vital signs and instructed her to get Resident #158 in the shower to wash away the blood. Staff G said the resident ' s pajamas were soaked in blood. Staff G stated Staff B assisted to stand Resident #158 up, pivoted her into a shower chair, washed her off, then started to dress the resident. Staff G recalled Resident #158 said it hurt and told them not to push when they applied the gripper socks and pants. Staff G stated Staff D helped to push the shower chair next to the bed, they stood Resident #158 and pulled up her pants, pivoted her and put her into the bed. During an interview on [DATE] at 7:50 AM, Staff A, RN Clinical Administrator stated she did not know about the fall until the morning of [DATE] at 6:30 AM and she said to send the resident to the hospital. Staff A stated the staff knew they could call 24/7 and the expectation was to call with a fall. During an interview on [DATE] at 9:05 AM, Staff H, Physician responded if anyone found a resident on the floor, he would expect the staff to look for any visible wounds, assess for pain in any extremity and if they had a visible head wound, there may be a hemorrhage so of course to call 911. Staff H stated the staff could call 24/7 to report a fall and receive orders for treatment. In a subsequent interview on [DATE] at 10:28 AM, Staff H, Physician stated a review of the call logs revealed that there was no call for a fall on Resident #158 and he did not remember receiving one. Staff H stated he found a fax dated [DATE] at 10:45 PM that documented Resident #158 was found on the floor on her right side, her range of motion and neuro's were normal, she had a hematoma and complained of pain all over. Staff H commented that looking at the fax, the staff should have called 911. Staff H stated another fax received on Monday [DATE] at 5:49 AM documented the resident transferred to the local hospital. Staff H said a 2nd fax received on [DATE] at 3:47 PM notified him of the resident's death, 2 hours after Resident #158 passed away. During an interview on [DATE] at 8:08 AM, Staff E, CNA reported working for the facility for 13 years. Staff E stated on [DATE] at 10:00 PM she received a report that Resident #158 fell and the other CNA's had showered her. Staff E recalled Resident #158 wore a nightgown and laid in bed shaking. Staff E said the resident didn't verbalize and she didn't even touch the resident that night as the resident laid at the head of the bed but had turned herself around with her head at the foot of the bed. Staff E voiced she didn't touch the resident, provide check and change care, or turn the resident because she didn't want to cause her any more pain. Staff E reported the resident laid in the fetal position in bed all night shaking. Staff E voiced the resident was shaking really badly and the resident did not shake normally and therefore Staff E was not comfortable with doing anything with the resident. Staff E recalled thinking why didn ' t they send her out. Staff E stated that Resident #158 remained at the facility as of 6 AM when her shift was complete. Staff E stated the Memory Care Unit was where she worked and Resident #158 normally slept all night and would get up when she needed to use the bathroom. During an interview on [DATE] at 11:00 AM, Staff B, RN stated Resident #158 was able to sit up, had full range of motion to her arms and legs, and no complaints of pain. Staff B said she wanted the resident cleaned up as she had dried blood in her hair, on her hands, and legs. Staff B stated she gave the instruction for the CNA's to get Resident #158 showered. Staff B said while she observed, the resident alternated cradling her arms in her lap. Staff B stated the CNA's put the residents arms in her gown, they wheeled the shower chair over to the bed and put the resident to bed onto her right side and covered her. Staff B said she completed another set of vital signs and neurological checks. Staff B reported when she returned an hour later the resident slept and she was sleeping every time Staff B went into her room. Staff B stated she had notified the On-Call Nurse, Staff A, with a text, who responded ok. Staff B said she continued neuros during the night and the resident ' s eye was bruised. Staff B stated Staff E called at midnight, reporting Resident #158 was experiencing pain. Staff B commented the resident didn't look like she was in distress, nothing unusual. Staff B stated that Staff E reported Resident #158 was moving around in her bed, laid toward her headboard and other times her head toward the foot board. Staff B administered an as needed (prn) Tylenol at midnight per the standing order. Staff B voiced she didn't document it as the stomach pain was normal for the resident. Staff B stated she did not notify the doctor in this case as there was a standing order. Staff B reported at 4:00 to 5:00 AM, the resident said ouch, don't touch her arm. Staff B stated she updated Staff A with a text at that time that she was working on sending the resident out for further evaluation. Staff B stated she made the decision to send the resident out. Staff B said she notified the POA at 4:00 -5:00 AM letting her know the resident fell the night before, cut above her eyebrow, they cleaned her up in the shower, completed neuro checks and she had a change. Staff B stated the resident didn't want to move her right arm so Staff B wanted to send the resident out if the POA was okay with it. Staff B stated she called the provider to get the order and called the ER at the local hospital to give a report. During an interview on [DATE] at 2:30 PM, Staff L, Advanced Registered Nurse Practitioner (ARNP), stated she remembered receiving a call on [DATE] from the nurse asking permission to send the resident to the hospital. Staff L reported she was on call for the providers in that area and at the hospital emergency room (ER). Staff L stated the staff did not call the physician when Resident #158 fell at 9:00 PM on [DATE]. Staff L voiced the whole thing was not right as Staff B said they found the resident down, put her back to bed, and the resident didn't want to get up in the morning, so they needed permission to send her. Staff L stated the resident had a head injury, there was shortening of the resident's right leg and it was rotated outward, the resident guarded her right arm screaming if staff touched it, and they gave the resident nothing for her pain. Staff L stated the staff should have called the on-call provider at the time Resident #158 was found on the floor to seek treatment orders; the on-call providers take calls 24/7. The policy titled Fall Prevention and Management dated [DATE] revealed: a. The Clinical Administrator is responsible for assuring implementation of this policy. b. All staff are responsible for implementing the intent and directives contained within this policy. c. The Nurse will immediately evaluate the resident for any injury, change in status and/ or pain and will proceed with emergency procedures and interventions as indicated. d. Suspected head injury or possible significant injury or fracture: the resident is not to be moved until emergency personnel have arrived unless it is determined that the resident is at risk for injuring self further or is at risk for further injury if they are not moved. e. The Nurse will notify 911, the primary physician and/or Nurse Practitioner (NP) and the RN in charge as indicated based on the initial evaluation and the resident care plan. f. The Staff Nurse will complete the resident Occurrence Report and notify the physician and responsible party. g. Minor Head Trauma or Unwitnessed Fall where the resident is not able to state if they hit their head 1. Determine vital signs including orthostatic blood pressures. 2. Determine circumstances leading to the fall and interventions. 3. Perform Neuro Checks: a. Day 1: i. Every 15 minutes x 2 ii. Every hour x 2 iii. Every 2 hours x 2 iv. Every 4 hours x 2 b. Days 2 and 3: i. Every shift c. Alert the Physician or NP with any changes. h. An entry into the medical record will be completed to include: patient appearance at time of discovery, patient response to event, evidence of injury, location, medical provider notification, responsible party notification, nursing actions.