**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to follow up timely after a fall when one resident experienced a fall from bed, staff assisted the resident to lower to the ground, heard a loud pop and failed to assess the cause of the pop or report the pop and/or the resident's request for pain medication to the physician. Staff improperly transferred the resident back to bed after the fall. The evening shift certified nursing assistant (CNA), responsible for the resident at the time of the fall, failed to inform the oncoming night shift CNA that the resident had fallen. When the resident complained of pain to the night shift CNA, he/she failed to notify the nurse of the expressed pain. This resulted in one resident (Resident #105) having a delay of approximately 13 ½ hours from the fall until the resident was sent to the hospital for treatment. The resident expressed pain to staff on all shifts following the fall. The fall resulted in a fractured femur that required surgical repair. The facility failed to assess and follow up for one resident (Resident #70) who had a change in condition after returning to the facility from the hospital after a fall. The resident experienced shortness of breath and reported discomfort to the sternal (mid chest) area. A CNA reported the change in condition to the nurse who failed to follow up on the resident's condition. The resident expired later that day. In addition, the facility failed to appropriately assess and document a wound for one resident (Resident #93). The sample was 25. The census was 125. 1. Review of Resident #105's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated [DATE], showed: -Cognitively intact; -No behaviors or mood concerns; -Extensive assistance of two person physical assist required for bed mobility, transfers and toilet use; -Limitation in range of motion impairment on both sides, upper and lower extremities; -Wheelchair used for mobility; -Diagnoses included high blood pressure, fracture, and seizure disorder; -Occasional pain that did not affect sleep or day-to-day activities. Review of the resident's care plan, in use at the time of the survey, showed: -Activity of daily living (ADL) functional/rehab potential: Resident requires assistance with daily ADL care: -Will have daily ADL care needs met: -Extensive assistance with transfers. Two person staff support with transfer using sling with Hoyer lift (mechanical lift). Hoyer lift to be used with two person assist at all times. Extensive assistance with mobility. Two staff support with mobility. Uses a wheelchair device for mobility. Half assist rails for bed positioning, bed mobility. Incontinent of bladder at times, please toilet when needed. Usually continent of bowel, needs assist times two to toilet. Extensive assistance with toiling. Need two staff support with toileting; -Falls: Resident has potential for falls related to limited movement with impaired balance: -Resident will remain free of injury related to fall; -Encourage resident to call for assistance with transfers; -Pain: Resident has chronic pain related to Rheumatoid Arthritis (degenerative joint disease causing inflammation and pain) as evidenced by complaint of pain at level 4 at times on scale of 0-10 (scale used to measure pain based on a resident's response of 0-10, 0 indicates no pain and 10 indicates the worse pain possible): . He/she states that the pain is consistent but tolerable at 3-4. Now receives additional scheduled pain medication: -Resident will demonstrate adequate pain control as evidenced by verbalizing satisfaction with level of comfort and ability to participate in ADLs; -Report uncontrolled pain to physician. Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity and precipitating factors of pain. Instruct resident on pain scale values (0-10) and encourage to notify staff when pain levels are increasing and/or medication is not effective. Monitor for non-verbal signs of pain such as grimacing, irritability, moaning, body language, guarding, etc. daily. During an interview on [DATE] at 9:10 A.M., the assistant administrator said on [DATE] therapy did a screen on the resident that showed the resident only required assist of one for bed mobility. Nursing staff were educated on the change with bed mobility and the decision to use a sliding board for transfers. When therapy works with a resident and once they feel they can change the resident's care levels, they start training staff on the floor. Then in huddle, they report their new recommendations and it is then added to the care plan. The MDS coordinator did not update the care plan but the information was passed on in report. On [DATE], the care plan should have been updated. Review of the resident's physician order sheet (POS), showed: -An order dated [DATE], up in wheelchair per Hoyer lift; -An order dated [DATE], for hydrocodone/acetaminophen (Norco, narcotic pain medication with Tylenol) 5-325 milligram (mg). One tablet by mouth every 6 hours as needed for pain; -An order dated [DATE], may have half assist rails for bed positioning and mobility and assist with transfers; -An order dated [DATE], sliding board transfer use for wheelchair to bed to wheelchair transfer. Resident requires contact guard assist and occasional verbal cues on safety and assist to position the chair and bed properly. Do not leave the sliding board in the resident's room, as needed. Review of the resident's pain assessment, documented under resident vital stats, showed: -On [DATE] at 12:26 P.M., a pain level of 0 (indicated no pain) numeric scale. Review of the resident's progress notes, showed: -On [DATE] at 9:10 P.M., the CNA had the resident on the bedpan, resident had finished toileting when CNA asked the resident to roll off of the bedpan. Resident attempted to roll off as directed, momentum carried the resident out of bed to the side of the bed where he/she ended on his/her knees and holding the side rail. Range of motion within normal limits. Resident did not strike head. Vital signs: temperature 97.8, pulse 97, blood pressure 148/86, oxygen saturation (percentage of oxygen in the blood) 97%. Physician notified of incident. Resident's family notified of incident. Resident resting in bed, will monitor as needed. Review of the resident's medication administration record (MAR) for [DATE], showed: -No documentation of the as needed hydrocodone/acetaminophen administered on [DATE]; -Hydrocodone/acetaminophen administered on [DATE] at 8:00 A.M. Review of the resident's controlled medication log, showed staff removed one hydrocodone/acetaminophen 5-325 mg tablet on [DATE] at 10:00 P.M. During an interview on [DATE] at 3:14 P.M., Nurse K said the resident called his/her family member and complained of pain. The family member called and requested pain medication be given. It was administered. The administration should have been documented. Further review of the resident's progress notes, showed: -The next note, dated [DATE] at 3:24 A.M. (6 hours and 14 minutes after the resident's fall), resident continues on follow up for a fall with no apparent injuries. No complaints or distress. Currently resident in bed. Call light is in reach; -On [DATE] at 6:32 A.M., no behaviors to note; -On [DATE] at 4:32 P.M., (late entry): -At 7:50 A.M., CNA reported that the resident was having pain to his/her right knee. Upon assessment, resident's right leg was turned outward. His/her leg swollen, hot to touch and painful; -At 8:00 A.M., paged Physician J, awaiting call back. As needed Norco 5-325 mg one tab and routine fentanyl (narcotic pain medication) 12 micrograms (mcg) one patch applied to the upper left chest. This writer informed CNAs not to get resident up for breakfast until further notice; -At 8:30 A.M., Physician J notified of the resident having pain to the right leg. New order received to get STAT (immediately) x-ray of right femur (long bone of the leg), right hip and right knee; -At 8:40 A.M., mobile x-ray company notified of new order, awaiting arrival; -At 8:50 A.M., notified resident's family of the above new orders; -At 9:00 A.M., mobile x-ray company technician arrived to do STAT x-ray of right femur, hip and knee. As needed Norco 5-325 mg was effective, some relief noted but resident still had facial grimacing; -At 9:40 A.M., results of x-rays are here and showed acute fracture distal femur; -At 9:50 A.M., paged Physician J, awaiting call back; -At 10:15 A.M., Physician J returned page. This writer notified physician of x-ray results. New order received to send the resident to the hospital for evaluation; -At 10:20 A.M., notified the resident's family member of new orders to send the resident out and x-ray results; -At 10:35 A.M., called hospital and report was given to emergency room nurse; -At 10:45 A.M., called ambulance company for STAT transport services to the hospital; -At 10:55 A.M., the ambulance company arrived to transport the resident via two emergency medical technicians per stretcher. Resident was stable at time of departure. Review of the resident's Situation, Background, Assessment, Recommendation (SBAR) professional communication form, dated [DATE] at 8:00 A.M., showed: -The change in condition, symptoms or signs is/are: Right leg pain; -This started on [DATE]; -Since this started it has gotten: Worse; -Things that make the condition or symptoms worse are: Any type of movement when doing ADLs; -Things that make the condition or symptoms better are: As needed Norco 5-325 mg and no movement to right leg; -Needs more assistance with ADLs, decreased mobility, weakness or hemiparesis (weakness on one side of the body); -Describe symptoms or signs: Right leg pain, cannot be moved without complaints of pain; -Increase in pain noted and reported to right leg; -X- ray, transferred to hospital. Further review of the resident's pain assessment, documented under resident vital stats, showed: -On [DATE] (no time specified), 7 (midway between severe and very severe pain) faces scale (numeric scale assessed using the resident's facial expression when the resident is unable to verbalize a number); -No further documentation of pain in [DATE]. Review of the resident's hospital records, showed: -admitted [DATE]; -Right knee x-ray results, dated [DATE] at 2:16 P.M., showed there is a displaced (removal from normal position) distal (far end) femur fracture (fracture of the lower end of the right leg long bone). The distal fracture fragment (a small part broken from a larger entity) is displaced laterally (to the side) 2.3 centimeters (cm). There is override (slipping of either part of a fractured bone past the other) of the fracture line of about 4.5 cm. The femur and bones of the knee are osteopenic (having osteopenia, reduced bone mass) and there is severe degenerative arthritis of the right knee. The distal femur fracture shows posterior (back side) displacement of 4.1 cm. There is a knee joint effusion (increased fluid buildup); -Portable right femur two view x-ray, dated [DATE] at 3:01 P.M., showed total right hip arthroplasty (surgical procedure to reconstruct the hip) is observed in anatomic alignment. Diffuse (wide spread) osteopenia is present. An oblique (situated in a slanting positron) distal right femoral diaphysis (portion of the long bone between the ends) fracture is present with nearly one shaft (diameter of the bone) width lateral and posterior displacement of the distal fracture fragment. There is mild anterior (front side) angulation (deviation from a straight line) of the distal fracture fragment. Three compartment right knee osteoarthritis (degenerative joint disease) is observed. Review of the facility's fall policy, revised [DATE], showed: -The purpose of this procedure is to provide guidance for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall; -If a resident sustains a fall, or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated; -A licensed nurse shall notify the resident's attending physician and resident representative of the event. The licensed nurse shall document the fall in the resident's clinical record; -A licensed nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident clinical record; -An incident report shall be completed for resident falls by a licensed nurse after the fall occurs. Observation during the initial screening of residents, on [DATE] at 10:29 A.M., showed the resident in room in bed. A head/neck pillow in place. The resident had facial grimacing and a pained look. The resident said he/she was in pain and declined to talk further. During an interview on [DATE] at 1:57 P.M., the Director of Nursing (DON) said CNA L was the only staff person in the room at the time the resident fell. He/she was placing the resident on the bed pan. During an interview on [DATE] at 3:28 P.M., CNA L said he/she was the CNA assigned to the resident the evening of the fall. Staff know how to care for residents based on the care plan that is available in the electronic medical record. Staff also pass on shift report. Based on shift report, the resident required assist of one with bed mobility. He/she did not view the care plan. The last time he/she had cared for the resident prior to the night of the fall was approximately 6 months ago. The resident utilized a hand rail on both upper sides of the bed for mobility. At the time of the resident's fall, he/she stood on the right side of the bed and the resident fell off the left side of the bed. The resident did not really fall. He/she rolled to the left and the entire bottom half of the resident's body started to fall off the bed. He/she grabbed the resident's shirt while yelling for the nurse to come in. Nurse K saw what was happening and started to move the bed further away from the wall so he/she could fit between the bed and the wall. At the time of the resident's fall, the bed was not completely against the wall but it was close enough that the nurse could not fit. Additional CNAs came into the room to help. Nurse K assisted to lower the resident to the floor. While lowering the resident to the floor, there was a loud pop. The nurse then completed an assessment of the resident. The resident was able to move all extremities and did not say he/she had pain at that time. Once the nurse was done with the assessment, CNA T, another CNA and him/herself assisted the resident to bed. The nurse said to just lift the resident into bed. Some staff grabbed the resident's legs and other staff grabbed the resident's upper body. The staff then got the resident situated in the bed and the resident started to complain of right knee pain. The nurse had gone to the nurse's station so he/she went and told the nurse the resident had pain and asked if he/she could get the resident an ice pack. The nurse said that was fine. He/she checked on the resident several more times and he/she seemed relatively ok. He/she was the CNA for the resident until his/her shift ended at 11:15 P.M. and he/she was not sure who the CNA was who took over after the end of the shift. During an interview on [DATE] at 8:42 A.M., Family Member M said he/she was notified of the resident's fall. The resident had to have a surgical procedure to have a rod placed in his/her femur to repair the fracture. During an interview on [DATE] at 8:46 A.M., Family Member N said he/she was still trying to find out the circumstances surrounding the fall. The resident told him/her that he/she fell while transferring to the bed and said the person transferring him/her fell on top of him/her as well. The facility is saying the resident fell while being removed from the bed pan. The facility reported he/she was holding onto the bed rail. His/her bed should have been against the wall. The resident had surgery yesterday ([DATE]). The facility said they did the x-ray at the facility and the fracture did not require surgery so family was surprised when it was found out the resident did require surgery. Right now the resident is out of it and is on pain medications. Surgery went well. During an interview on [DATE] at 10:23 A.M., CNA O said he/she worked on evenings [DATE] and assisted the resident after the fall. He/she was not assigned to the resident. He/she was going to check on another resident and walked past the resident's room. He/she saw the nurse and two CNAs in the room and the nurse was standing over the resident. They said CNA L was putting the resident on the bed pan when the fall occurred. After the nurse assessed the resident, he/she said two staff need to be at the top of the resident and two at the bottom in order to transfer the resident back to bed. CNA O said he/she had never worked with the resident before. CNA L and the nurse said the resident required a Hoyer lift but the way he/she was positioned on the floor, the bed was in the way to get the Hoyer lift there. He/she did not know why staff did not move the bed to allow room for the Hoyer lift. There were two other CNAs who assisted to transfer the resident to bed. The two other CNAs grabbed the resident's thighs and he/she was at the top of the resident and pulled him/her by the shirt at the shoulder area. He/she held the resident's shirt and not the shoulders so he/she would not hurt the resident. The nurse did not help. The resident was yelling really bad that he/she was hurting. Staff had said something about a pop they heard, but he/she was not in the room at the time the pop was heard. The nurse and the CNA responsible for the resident said the leg had popped. After staff got the resident into bed, the resident was saying his/her leg was hurting bad and it appeared red. The nurse said he/she was going to call the doctor. During an interview on [DATE] at 10:57 A.M., CNA P said he/she was the CNA assigned to care for the resident on the night shift, [DATE] through the morning of [DATE]. No one passed on in report that the resident fell and he/she knew nothing of the fall or the need to monitor the resident post fall. When he/she did his/her first round on the resident, he/she just looked in the doorway. The resident looked back at him/her. The television was on. The resident did not say anything. At 1:00 A.M. or 2:00 A.M., he/she went to check on the resident. His/her bed was way up both the legs and head of bed were raised. When he/she went to let it down the resident yelled out and said his/her leg hurt. He/she checked the resident's brief for incontinence and when done the resident said he/she was fine. Normally, the resident would have said something about having the fall, but the resident was just a little out of it. He/she did not tell the nurse about the pain and just assumed it was the same complaints as usual. He/she did not know there was a fall. Typically staff pass on in report if there is a fall. During an interview on [DATE] at 11:31 A.M., CNA Q said he/she was the CNA assigned to care for the resident the day shift of [DATE]. He/she was told nothing about the fall. Nothing was passed on in report. Upon entering the resident's room, the resident was in a lot of distress. He/she identified the pain to be in the right leg. The resident was not one to complain. Later that morning, CNA T, who had worked the evening shift, informed him/her of the fall. The fall should have been passed on in report. He/she reported the pain to the day shift nurse. During an interview on [DATE] at 11:40 A.M., Nurse R said he/she was the nurse assigned to the resident on the day shift, [DATE]. He/she was told in report from the night nurse that the resident was on incident follow-up, that he/she didn't hit floor but was lowered to floor. He/she was told nothing about any report of pain or injury. After CNA Q reported the pain the resident was experiencing, he/she went to the room and assessed the resident. The resident's right knee and leg were swollen, hot to the touch, and turned outward. When he/she went to go near the leg, the resident started to scream. He/she called the doctor and reported the resident's symptoms. The doctor said to get x-rays. The x-rays came back as broken. He/she asked the DON if they should send the resident out and she said call the doctor first. He/she placed a call to the doctor and called the family. When the doctor called back we sent the resident out to the hospital. During an interview on [DATE] at 3:02 P.M., Nurse S said he/she was the nurse assigned to the resident on the night shift, [DATE] through the morning on [DATE]. He/she was told of the fall and that the resident had no injury and range of motion was fine. He/she was told that they used two staff to put the resident on the bed pan but when they took the resident off, they only used one person. The resident required two person with a Hoyer for transfers and two person assist for bed mobility. To the best of his/her knowledge, the resident slept though the shift. He/she was never informed of the resident having pain. He/she never had to go into the room to provide care. It was in the morning when they were messing with him/her that staff realized there was pain. During an interview on [DATE] at 3:14 P.M., Nurse K said he/she was the nurse assigned to care for the resident on evening shift [DATE], the evening of the fall. The resident required assist of one with activities of daily living and assist of two with a gait belt for transfers. Right now therapy staff are the only staff that can use the sliding board. He/she was in the hall when he/she heard CNA L call out and ask for help. He/she entered the resident's room and asked what happened. The resident was between the bed and wall, in a kneeling position. Both arms were reached up and holding onto the side rail. He/she moved the bed to get access to the resident and had to support him/her to keep him/her from hitting his/her face. When assisting the resident to the floor, he/she heard a loud pop but he/she did not know what it was. He/she would have assumed if it was a bone the resident would have screamed. The pop was so loud that he/she startled and yelled out. He/she did a visual check for deformities and did not see any bones sticking out or any misshapen legs. He/she checked the resident's eye response, obtained vital signs and completed range of motion. The resident denied pain at that time. He/she then called the physician and family. He/she was not in the room when staff assisted the resident back to bed. After talking to the family, the family called back and requested to talk to a supervisor. He/she transferred the call to the other building where the supervisor was. The supervisor then called and told him/her the family member said the resident wanted pain medication. The CNA also got ice for the resident's leg. During an interview on [DATE] at 3:41 P.M., Physician J said he/she was called the evening of the resident's fall and then again the next morning. He/she was not told of a loud pop. That evening, [DATE], he/she was called by the nurse who said that the CNA was trying to help the resident get off the bed pan and dropped him/her and that he/she fell to the ground. It was reported that the resident had no pain, no injury and was ok. If he/she would have been told there was a pop and the resident required pain medication, he/she would have ordered the x-rays immediately. The resident is chronically debilitated already and this will make things more difficult for him/her. During an interview on [DATE] at 7:45 A.M., CNA T said he/she worked on evenings on [DATE]. He/she assisted after the fall, but was not assigned to the resident. Prior to the fall, he/she assisted CNA L to transfer the resident from the wheelchair to bed with the use of a Hoyer lift and then assisted CNA L to get the resident on the bed pan. He/she told CNA L to let him/her know when he/she need help to take the resident off the bed pan. He/she was in a different room and heard a noise and CNA L scream for the nurse. When he/she entered the room, he/she saw the nurse between the bed and wall. He/she helped move the bed away. The nurse assisted the resident down to the floor because the resident was still holding on. There was a loud pop and the nurse said oh, my! What was that? The nurse said staff need to put the resident back into bed. He/she cannot remember who all helped. The nurse instructed staff to grab the resident and lift him/her to bed. He/she held the resident at the bottom. The resident said his/her knee hurt and it was red. CNA L gave the resident ice. The resident did report pain. During an interview on [DATE] at 2:24 P.M., the DON said staff know how to care for residents by viewing the care plan. Staff should be assessing residents for pain during rounds. They should observe for pain or ask if the resident had pain. If the resident had pain after the fall this should be documented. After the fall, the resident should have been transferred back to bed with the Hoyer lift. Staff should never lift a resident by grabbing onto the arms and legs. The evening shift nurse should have completed the SBAR for the fall. If the nurse heard a loud pop when lowering the resident to the floor, this should have been reported to the physician. 2. Review of Resident #70's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Supervision, oversight, encouragement, or cuing required for bed mobility, walking in the room, walking in the corridor, locomotion on and off the unit and eating; -Limited assistance required for personal hygiene, toilet use, dressing and transfers; -Diagnoses included heart failure, high blood pressure and dementia; -No pain, no falls; -Oxygen therapy not indicated as used. Review of the resident's care plan, showed: -Has potential for falls related to recent admission to community: -Resident is at risk for falls related to change in environment. Resident wants to remain free from injury related to falls; -Keep pathways clear and provide adequate lighting, reeducate to call for assistance when feeling unsteady; -No documentation of the resident's need for oxygen therapy. Review of the resident's medical record, showed the resident designated as do not resuscitate (DNR, no life saving measures desired). Review of the resident's progress notes, showed: -On [DATE] at 6:56 P.M., fall documentation: resident noted to be lying on floor by CNA at 10:00 A.M., on [DATE]. Resident noted to be on back with his/her head near the air conditioning unit and his/her legs were stretched out in the room. Resident stated I fell and hit my back on the air conditioner unit. Resident screamed out my back hurts when range of motion and assessment was attempted. Resident refused range of motion. This writer advised CNAs not to move resident. Complaints of back pain as needed Tylenol administered. At 10:25 A.M., paged the physician, awaiting call. At 10:40 A.M., Power of Attorney (POA) notified and requested for resident to be sent to the hospital. At 10:40 A.M., hospital emergency room nurse notified about resident's changed in condition. At 10:55 A.M., 911 called. Resident stayed on the floor with charge nurse at his/her side the whole time, until emergency medical technicians (EMTs) transferred him/her to the stretcher; -On [DATE] at 6:59 P.M., received report from hospital that all x-rays negative for fracture and breaks. Stated resident was in pain and described it as severe pain; -On [DATE] at 7:03 P.M., resident returned to the facility via ambulance. Chief complaints is shortness of breath. Resident placed on 3 liters (L) oxygen to keep oxygen saturation (percentage of oxygen in the blood) above 93% (normal 95% through 100%); -On [DATE] at 7:56 P.M., follow up note. Resident refused skin assess due to severe back pain after hitting back on air conditioning unit; -On [DATE] at 2:48 A.M., readmit status, resident returned from hospital after fall. Purple bruising to the left upper extremity. Complaint of pain 3/10 (based on a scale of 0 to 10. 0 Indicates no pain and 10 indicates the most severe pain) back pain but refused Tylenol. Helped adjust bed and pillows for comfort, resident on 3L oxygen, no shortness of breath or complaints. Reminded to use call light before he/she gets out of bed for precaution as he/she is used to being independent and without oxygen. Bed in low position, call light and personal items in reach. Vital signs: Temperature 97.9, blood pressure 135/82, heart rate 87, respirations 18, oxygen saturation 97% on 3L oxygen. Neurological check within normal limits; -On [DATE] at 2:55 P.M., resident continued on follow-up. No distress or discomfort. Resident refused to eat lunch. By mouth fluids encouraged. In room with call light in reach; -On [DATE] at 3:16 P.M., resident with recent fall. Recommending physical therapy evaluation to follow to assess mobility and balance; -On [DATE] at 2:49 A.M., resident continued on follow-up for a fall with bruising. No complaints of or distress, currently resting in bed, call light in reach; -On [DATE] at 1:07 P.M., resident was given wrong medication. Resident was given Norco (narcotic pain medication) 5-325 milligram (mg) one tab by mouth which was meant for his/her roommate. But by me being new and not told of the resident's confused mental status, when asked if he/she was (roommate's name) the resident answered yes. Medication was given and as soon as it was realized the medication was given to the wrong person, immediately notified coworker and assistant director of nursing (ADON) of the medication error. Physician notified and instructed to monitor resident for the next 6 hours. Family member notified. Vital signs: Blood pressure 155/90, heart rate 88, respirations 16, oxygen saturation 96% on 2L of oxygen. Resident assisted to wheelchair with CNA and this writer, to eat lunch. Resident sitting in chair with no complaints noted at this time; -On [DATE] at 2:54 P.M., resident sitting in chair relaxing. Has no complaints of pain noted at this time; -On [DATE] (note entered at 7:57 P.M., over three hours after the resident expired, and did not specify what time this observation occurred) Resident had complaints of irregular heartbeat. Did a manual pulse check of the radial pulse and the results was 66 beats per minute. Call sent out to physician and family; -No further documentation of assessments of the resident, monitoring of the resident, documentation of change in condition and/or vital signs taken. During an interview on [DATE] at 12:31 P.M., Physician EE said he/she was notified of the fall and when the resident received the wrong medication. The next notification he/she received was when the resident expired. He/she was not notified of a change in the resident's condition. During an interview on [DATE] at 1:06 P.M., the resident's family member said he/she was notified of the fall and when the resident received the wrong medication. The next notification made was after the resident expired. Further review of the resident's progress notes, showed: -On [DATE] at 8:37 P.M., called to resident's room at 4:30 P.M., resident slumped in chair. Checked for vital signs. No vital signs present. Resident non-responsive. Resident deceased at 4:45 P.M. Physician notified, confirmed death diagnosis as congestive heart failure (CHF). Family notified, had concerns about earlier medication error. Family wanted coroner to do autopsy. Pathologist notified of request and the events of the medication error. Pathologist findings were that the amount of t[TRUNCATED]