**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of clinical records and other pertinent facility documentation it was determined that the facility failed to: a.) provide adequate supervision for a resident identified as a high risk for falls, b.) implement appropriate fall prevention interventions for a resident after sustaining multiple falls with a major injury, c.) update the resident's Care Plan in a timely manner, d.) perform neuro-checks (assess an individual's neurological functions, motor and sensory response, and level of consciousness) as per facility policy for a resident who had three falls resulting in head injuries. This deficient practice was identified for one of five residents, (Resident #193) reviewed for accidents. The resident had five (5) falls since 01/04/23, and three (3) out of 5 falls resulted in the resident sustaining head injuries. The deficient practice was evidenced by the following: On 01/20/23 at 10:56 AM, the surveyor was touring the 300 unit and observed the staff mechanically lifting Resident #193 into a geri-chair (specialized recliner) off the floor, in front of the nurse's station. The surveyor asked the Registered Nurse Unit Manager (RN/UM) what happened, and the RN/UM stated that Resident #193 fell out of the wheelchair in front of the nursing station. The admission Record indicated that Resident #193 was admitted to the facility with the diagnoses which included but were not limited to metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), unspecified falls, diabetes mellites (DM), and Dementia. The admission Minimum Data Set (MDS), an assessment tool used t0 facilitate the management of care dated 01/09/2023, indicated that the resident had short term and long-term memory loss and had impairments in cognitive decision making. The MDS also indicated that the resident required extensive assistance with activities of daily living and had a history of falls. On 01/23/23 at 11:07 AM, the surveyor observed the resident sitting in a specialized recliner at the nurse's station. The resident was unable to be interviewed due to cognitive impairments. The resident was quiet and resting. On 01/23/23 at 11:27 AM, the surveyor conducted a telephone interviewed the resident's responsible party (RP) who stated that Resident #193 had about 10 falls both at home and in the facility. The RP explained that the resident was experiencing falls at home and required more supervision than the family could provide and decided to admit Resident #193 to the facility for more supervision. The RP stated that Resident #193 had to be sent to the hospital a couple times due to falling in the facility. The RP further added that they did not know all the details regarding how Resident #193 had fallen. The RP requested the surveyor to inquire and review the Resident's medical record to find out how many times the resident fell. A review the resident's Care Plan (CP) dated 01/05/23, reflected Resident #193 was at risk for falls due to lack of safety awareness, decreased mobility, fatigue, anemia and diabetes mellitus. A review of the Progress Note (PN) dated 01/04/23 at 17:47 (5:47 PM) indicated that Resident #193 was admitted for the following reason(s): Status post fall and ambulatory dysfunction. On 01/25/23 at 11:25 AM, the facility provided the surveyor with incidents and accident reports for Resident #193 which indicated that Resident #193 had falls on the following dates: The surveyor reviewed the facility Fall Investigation Statement (FIS) dated 01/12/23 at 4:30 PM, written by Licensed Practical nurse (LPN#3) for fall #1. The FIS indicated that Resident #193 was observed lying on the floor on the right side next to the specialized recliner in front of the nurse's station. The fall was witnessed by the ward clerk. The Risk Management System form (RMS) #358 indicated that the resident did not bang or hit his/her head during the 01/12/23 fall. It also indicated that there were no injuries, and the RP and medical doctor (MD) were notified. The intervention on the RMS form indicated adding a non-skid mat to the cushion of the wheelchair to prevent the cushion from sliding. The CP further reflected that the intervention was not created until 01/24/23 but was initiated on 01/13/23. The surveyor reviewed the Risk Management System (RMS) form #359, dated 1/14/23 at 14:35 (2:35 PM) for fall #2 which reflected that Resident #193 was found on the floor in his/her room on his/her back, beside the wheelchair and verbalized pain to the back of their head. The nurse assessed the resident and observed a lump where the resident had complained of pain. According to the report, the resident was unable to explain what happened. The FMS indicated that a neuro-check was conducted, 911 was called and the resident was sent to the emergency room (ER). The FMS indicated that the resident had dementia, a lack of safety awareness and was impulsive. The FMS also indicated that the resident's son was visiting prior to the fall and left the resident alone in the room and did not inform nursing that he was leaving. A review of the PN dated 1/14/23 at 18:18 (6:18 PM,) indicated that the resident returned from the hospital to the facility around 5:00 PM. The PN further reflected while at the hospital the CT scan (several x-ray images) of the head and cervical x-rays were negative. The facility could not provide the surveyor with neurological checks for Resident #193 after falling and suffering a head injury on 01/14/23 at 2:35 PM. The surveyor reviewed the resident's CP which indicated interventions were not implemented on the resident's CP to prevent falls until 01/17/23, which was 3 (three) days after the resident fell and suffered a head injury. The intervention on the CP dated 01/17/23 indicated that staff were to remind family and visitors to inform staff when they were done visiting the resident. The FMS form #361 dated 1/14/2023 at 21:17 (9:17 PM), for fall #3 indicated that the resident was at the nurse's station after returning from the hospital after an un-witnessed fall. The resident continued to attempt to get up from the chair and walk and the nurse continued to reorient the resident that his/her lower extremities were weak and reminded the resident that he/she was unable to walk. The Licensed Practical Nurse (LPN #1) documented that she provided the resident with a coloring book with crayons. The nurse then had to leave the resident alone because another resident needed her care. During this time, another nurse called for her and she then found Resident #193 lying on the floor on right side. The resident's hands were covering his/her head and the resident had blood on his/her hands. The nurse applied gauze and pressure to the resident's head, another nurse called 911 and a third nurse came to clean and bandage the wound. The FMS form further indicated that the resident had a laceration to the back of his/her head and was sent to the ER. The FMS form indicated that the resident never lost consciousness. The surveyor could not find documentation that a neuro-check was performed on the resident after the resident had an unwitnessed fall and suffered a head injury. The FIS dated 01/14/23 at 6:00 PM and written by LPN#1 indicated that the resident was at the nurse's station accompanied by two nurses (LPN #1 and LPN #2) and a Certified Nursing Assistant (CNA #1). The statement indicated that the resident was attempting to walk, and the staff sat him/her in front of the nurse's station with a coloring book and crayons to redirect him/her. LPN#1 documented that she had to leave the nurses station to assist another resident when the resident got up and fell and was noted to be bleeding from the head. There was no documentation that a neuro-check was performed after the resident suffered a head injury or any further fall prevention interventions. The witness statement dated 01/14/23, from CNA #1 indicated that the resident was sitting at the nurse's station, and she had to answer another resident's light. When she came out from the other resident's room the resident was on the floor and was being sent to the hospital. The facility could not provide the surveyor with the statement from LPN #2, who was also identified as being at the nurse's station at the time the resident fell. The surveyor reviewed the CP and there were no interventions initiated after the third fall dated 01/14/23 at 6:00 PM and the resident sustained a laceration on the back of the head which required staples. Attached to the FMS #361 was a late entry progress note dated 01/16/23 at 18:48 (6:48 PM) that indicated that the interdisciplinary team (IDT) met to discuss Resident #193's fall of 01/14/23 and that the resident was receiving Physical Therapy (PT) and Occupational Therapy (OT) to work on transfers and ambulation. There were no new fall prevention interventions documented on the FMS form or on the CP regarding the resident's third fall at the nurse's station. On 02/02/23 at 11:10 AM, the surveyor interviewed the Rehabilitation Director (RD) who stated that Resident #193 received PT/OT from 01/5/23 through 01/24/23. The RD stated that the intervention for PT and OT services for the fall wasn't necessarily appropriate for the resident because the resident was already receiving services. The RD further explained that because the resident's cognitive status was limited, he/she wasn't benefiting from the PT/OT services provided and was discharged from services on 01/24/23 for that reason. A review of the PT Discharge Summary (DS) note dated 01/24/23, indicated that the resident was discharged from PT services due to reaching maximum potential. The DS note further revealed that the resident's performance varied depending upon level of alertness, arousal, and cognitive deficit. The PT discharge recommendations included the resident should be up out of bed daily, utilize a geri-chair for safety secondary to frequent falls, supervision when up out of bed, and use of a Hoyer lift due to fluctuations in the resident's performance. The surveyor reviewed the FMS #366 dated 01/16/23 at 20:58 (8:58 PM) for fall #4 which indicated that the resident was at the nurse's station and was provided with a coloring book, crayons, and towels for redirection; however, the resident was attempting to ambulate without assistance. The FMS indicated that the nurse sat with the resident for almost two hours along with other staff members because the resident had a history of falls. The FMS then indicated that Resident #193 was coloring and eating snacks when the nurse left the resident to take blood sugars for other residents. According to the FMS, when the nurse went into another resident's room, Resident #193, who was not being supervised, had fallen again at the nurse's station. The resident was sent to the hospital ER visit and three staples were applied to a laceration on the back of the resident's head. The PN dated 1/17/23 at 4:02 AM, indicated that Resident #193 returned from the hospital ER with staples to left side back of head and had no other injuries noted. The PN also indicated that the resident appeared in no pain and was in recliner chair at nurse station sleeping. The surveyor reviewed the PN and there was no documentation that fall prevention interventions were put in place immediately when the resident returned from the hospital after suffering a laceration to the scalp on 01/16/23. There were no neuro-checks documented or performed after the resident fell and hit his/her head and had a head injury. The surveyor reviewed the Resident's CP which was not updated until 01/17/23, to include new interventions to prevent the resident from falling. The fall interventions included the following: -Place the resident at the nurse's station for observation and safety -Staff to remind family/visitors to inform staff when done visiting. -When sitting in wheelchair, apply bilateral leg rest to aid in positioning -When sitting in the wheelchair, lock brakes. These interventions did not reflect that the resident continued to fall from a recliner while at the nurse's station and was not utilizing a wheelchair which was documented on the CP dated 01/17/23. The surveyor reviewed FMS #369 dated 01/20/23 at 11:06 AM, for fall #5 which indicated that Resident #193 fell from a wheelchair when in front of the nurses' station. The resident was assessed by the RN/UM, and it was determined that the resident had no injuries and no complaints of pain. Neuro-checks were initiated and completed. The FMS also revealed that fall prevention interventions for this fall were not initiated until 01/24/23, which was 4 (four) days after the fall. The CP reflected that on 01/24/23, fall interventions were put in place for this fall to include: -Scoop mattress -Fall matt next to bed -Staff to lay the resident down after meals -Toilet after meals On 1/26/23 at 8:35 AM, the surveyor observed Resident #193 in bed with two half side rails up at the top of the bed, bed in low position and a floor mat observed on the floor next to the door side of the resident bed. The resident was unable to be interviewed due to confusion and severe cognitive impairment. The surveyor interviewed CNA#2 who entered the resident's room. CNA#2 stated that the resident was very confused and was unsteady on his/her feet. She stated that the resident required extensive assistance with Activities of Daily Living (ADLs) but was able to feed himself/herself after setting up of tray. On 1/26/23 at 8:40 AM, the surveyor interviewed LPN #4 who stated Resident #193 was confused and had cognitive impairment. LPN #4 stated that sometimes the resident was verbal and sometimes not. He stated that Resident #193 required complete care with all aspects of ADL's and was frequently incontinent of bladder and bowel. He explained that at times, the resident requested to be toileted and could walk short distance with assistance. He stated that the resident wore incontinent briefs and was toileted every two hours. LPN#4 added that staff had to anticipate the resident's needs. He stated that the resident had fallen frequently since admission and was a risk for falls. He stated that when a resident had a witnessed fall, the staff performed a full assessment to include vital signs (VS), make sure the resident did not have any pain, injury, and perform neuro-checks for head injury or unwitnessed fall for 72 hours post fall. LPN#4 further stated that the staff were also were required to call the resident's primary care physician and the responsible party (RP). He stated that witness statements were obtained, and a Risk Management System Assessment (RMS) was completed along with a change in condition form and progress notes. He explained that when the staff fill out the RMS there was a section to put in a fall prevention intervention to prevent the resident from falling again. LPN#4 explained that an unwitnessed fall was the same process as a witnessed fall, but that it was the facility's protocol to initiate neuro-checks and complete them 72 hours post fall. He stated that if a resident hit their head or had head trauma, It's the physician's call to send the resident to hospital, but 90 percent of the time the resident is sent to the hospital for a head injury. LPN#4 stated that Resident #193 should have had neuro-checks for any unwitnessed fall or head injury however the neuro-check form was not in the resident chart and that the RN/UM must have the resident's neuro-check sheets in her office. He stated that the neuro-check sheets were usually completed and put into the resident hard copy of the chart, but that Resident #193's neuro-check sheets were missing and not in the resident's chart. He stated that the CP should be updated with interventions after a fall but that the LPNs did not have the access to update the CP. He further stated that interventions to prevent a fall should be done immediately post fall to prevent the resident form falling. On 01/26/23 at 10:20 AM, the Director of Nursing (DON) came into the conference room and handed the surveyor the neuro-check sheets for Resident #193's five falls since admission. The DON stated that the resident only had one neuro-check sheet completed for the fall which occurred on 01/20/22, and he/she did not have any other sheets to provide the surveyor. The DON stated that the nurses thought that if the resident went to the hospital, that neuro-check did have to be done. The DON stated the resident had fallen two times on 01/14/23, and once on 01/16/23, and suffered a head injury each time and there was no documentation that the resident had neuro-checks performed for 72 hours post fall as per the facility policy indicated. On 01/26/23 at 10:46 AM, the surveyor conducted a telephone interview with CNA #1 who stated that she remembered Resident #193 falling on 01/14/23, because she was the resident's primary care CNA that evening. CNA#1 added that she had written a statement regarding the fall. CNA#1 further stated that the resident fell right after her break. She explained that the resident's family member was visiting, and she asked the son to bring the resident to the nurse's station after the visit so that the resident could be supervised. When CNA#1 returned from her break, she had found out the resident had fallen in their room and had to go to the hospital. CNA#1 stated that the resident's first fall was on 01/14/23. CNA#1 then explained that when the resident returned from the hospital after the first fall, she performed PM care and the resident was placed at the nurse's station so that the staff could supervise the resident. She explained that the staff set the resident up with pen and paper to keep him/her occupied, but the resident wasn't using it. She stated that the pen and paper were just sitting in front the resident. She further added that the resident's attention span was not that long, and the resident would start using it and then lose interest quickly. CNA#1 further explained that she left the resident at the nurse's station so that she could answer another resident's call bell. She explained that there was a nurse at the nurse's station doing paperwork. She stated that when she returned to the nurse's station, all the nurses were surrounding the desk. She stated that LPN #2 was doing paperwork at the desk and couldn't get to the resident in time to prevent the resident from falling. She stated that the resident fell at the nurse's station and had sustained an injury to their head and there was a lot of bleeding, so the resident was sent to the hospital. On 01/26/23 at 10:51 AM, the surveyor attempted to telephone interview LPN #1 (Primary nurse for resident falls of 01/14/23) and did not get an answer. The surveyor left a message for LPN#1 to call back. On 01/26/23 10:57 AM, the surveyor telephone interviewed LPN #2 who was present on unit 300-unit on 01/14/23 and was sitting at the nurse's station doing paperwork when Resident #193 fell and suffered a head injury. LPN #2 stated that she worked on 01/14/23, completing admission documentation on the 300-unit. LPN #2 stated that she recalled when Resident #193 fell. LPN #2 stated, Yes. She did fall. She explained to the surveyor that the first fall happened on the 7:00 AM -3:00 PM shift in which Resident #193 fell and was sent to the hospital. She stated that herself and the primary nurse (LPN #1) were sitting at the nurse's station and LPN #1 was called to assist another resident in another room. She stated that while she was sitting at the nurse's station, her back was turned, and she was not facing the resident. LPN#2 stated that she was typing and looking in another direction and she did not observe the resident fall. She stated that she heard the fall. She added that the resident had blood all over because the resident was on a blood thinner, so they sent him/her back to the hospital. She stated that she didn't remember anyone asking her to write a statement even though she was present and at the nurse's station at the time the resident fell. She added that the resident was trying to stand up, so the staff gave the resident coloring books; however, the resident fell and hit his/her head. LPN #2 added that she was the only nurse sitting at the nurse's station at the time the resident fell because the resident's primary nurse (LPN#1) had gotten up to check on another resident. On 01/26/23 at 11:21 AM, the surveyor interviewed the Registered/Unit Manager, RN/UM who worked on the 300/400 units. The surveyor asked the RN/UM what the facility's process was for a witnessed fall and unwitnessed resident fall. The RN/UM explained that if a staff member witnessed a resident fall, then they would get a nurse and the nurse would immediately assess the resident and perform a head to toe assessment and obtain vital signs. If it appeared that the resident had no injuries, the staff would get the resident off the floor with an electric lift. She stated that if the resident had injuries, then they would call 911, the doctor, and the family or responsible party (RP). The RN/UM then stated that they would obtain witness statements from anyone that was involved with the fall, witnessed the fall or was in the area when the resident fell. She stated that the primary care CNA was responsible to fill out a statement even if they didn't witness the fall. She explained that the management would also get statements from anyone that was there and present in the area when the fall occurred. She indicated that a Risk Management System (RMS) form was completed and was given to the DON. The RN/UM explained that the IDT team consisted of nursing, therapy, recreation, and the interdisciplinary team would look at reasons why the resident could have fallen and think of things to do to prevent other falls from occurring. If a fall was an unwitnessed fall or if a resident suffered a head injury, then the staff would immediately initiate a neuro-check form. She stated that the nurse would be responsible for initiating the neuro-check form and that it was the responsibility of the RN/UM to make sure the neuro-checks were being conducted for the next 72 hours. The surveyor asked the RN/UM why Resident #193 did not have neuro-checks completed when the resident had suffered major head injuries on three different occasions (2 falls on 01/14/23 and 1 fall on 01/16/23). The RN/UM stated that the resident should have had neuro-checks done on the dates, however, did not have a response as to why the neuro-checks were not completed. The surveyor then asked the RN/UM why fall prevention interventions were not initiated or put on the CP until days later after the resident fell. The RN/UM explained that she did not implement the intervention for the CP because she was working on a medication cart that day. The surveyor reviewed the events that occurred regarding the two falls the resident had on 01/14/23 with the RN/UM. The RN/UM indicated that the first fall on 01/14/23 occurred at 1:27 PM. The RN/UM stated, We put [the resident] in front of the nursing station after returning from the hospital. The RN/UM stated that there was not a 3:00 PM - 11:00 PM supervisor to implement an intervention and the interventions were usually assessed by a RN/UM the next day. She stated, I don't want to say that they didn't do an intervention because they brought [the resident] in front of the nurse's station so someone could keep a better eye on [the resident] because the resident tried to get up on [his/her] own and walk and doesn't understand that [he/she] can't do that. The RN/UM further stated the resident could be supervised if they had the extra staff but that the intention of putting the resident in front of the nurse's station was to be supervised, however staff could not be at the nurse's station all the time because the nurses had to answer other residents call bells and had other duties and other residents to care for. The RN/UM stated that if a resident fell over the weekend, then interventions would not be updated on the CP until Monday. She stated that if a resident fell over the weekend, the nurses working over the weekend could put an intervention in place, however, it wasn't until Monday that the IDT would meet to discuss interventions for the resident and then the CP would be updated after the IDT discussed the event. The surveyor asked the RN/UM, When the resident fell two times on 1/14/23, were there interventions put in place immediately to prevent further falls? The RN/UM responded, No, the interventions were not updated until the 17th because the fall occurred on the 14th which was a weekend. The surveyor asked the RN/UM what interventions should have been put in place or would have been appropriate to prevent the resident from falling and getting injured again and the RN/UM replied that the staff gave the resident crayons and paper and sat next to him/her for over two hours. The RN/UM then added that the definition of supervision was when someone was sitting near the resident and being able to see them with their eyes. The RN/UM stated that the nurses and CNA could not always supervise the resident because they had other duties. The RN/UM revealed that from the moment the resident was admitted to the facility he/she was a fall risk and that was why his/her RP brought the resident to the facility. The RN/UM stated that she had suggested one to one supervision at the IDT meeting and was told by the team that they didn't have the staff to provide one on one supervision to the resident. She further stated that a 'one on one' meant that someone would be assigned to always supervise the resident. She also revealed that the social worker was trying to call a memory unit to see if a memory unit would be better suited for the resident. On 01/26/23 at 12:01 PM, the survey team interviewed the DON who stated that after any resident fell, the resident was assessed by the nurse to rule out any injury and the nurse would obtain vital signs. She stated that if it was determined that the resident had no injury, the staff would get the resident off the floor, collect statements from staff, complete the RMS, call MD and then call the family/RP. The DON further explained that interventions to prevent further falls and injury should be put in place at the time of the fall. She stated that she would expect that the staff would put an intervention to prevent further falls immediately after the fall to prevent the resident from falling again. The DON stated that the nurses all have access to the CPs and should have updated the care plan immediately to reflect new fall prevention interventions. The DON further stated that if a fall was unwitnessed or the resident had a head injury then neuro-checks should have been initiated. The DON told the surveyor that if the resident sustained a head injury as a result from a fall, and the resident could not be managed in the facility, then the resident would be sent to the hospital. The DON stated that after Resident #193 returned from the hospital on [DATE] and 01/16/23 and had suffered a head injury, neuro-checks should have been completed. The DON could not recall how long neuro-checks had to be done and had to refer to the facility policy. The DON confirmed that neuro-checks should have been completed for 72 hours after the resident fell and suffered a head injury on two falls that occurred on 01/14/23 and one fall that occurred 01/16/23, however the neuro-checks were not done. The DON added that the term supervision was attempting to watch a resident to the best of their ability. She added that supervision meant putting a resident in a common area. She further added that it was the facility's responsibility to put appropriate fall prevention interventions immediately in place to prevent further falls and injury. On 02/01/23 at 11:47 AM, the surveyor interviewed the DON in the presence of the survey team who stated that if the staff turned their back for 30 seconds, the resident would stand and still have a fall. The DON further stated that the resident would be appropriate for a facility with a specialized dementia unit and the facility was currently working on facilitating that for the resident. On 02/01/23 at 12:08 PM, the surveyor interviewed the facility's Administrator in the presence of the survey team who stated that the resident needed to be one-to-one supervision to prevent them from falling. The Administrator further stated that supervision meant that staff had to be present and observing the resident. The facility policy dated 10/24/22 and titled, Accidents and Incidents indicated that any resident fall resulting in a head injury, suspected head injury or an unwitnessed fall will be observed for neurological abnormalities by performing neuro-checks according to the Neurological Evaluation Policy and procedure after the accident occurs. Interventions to eliminate if possible and if not, reduce the risk of accident and incident have been identified and implemented. The facility policy dated 06/01/21 and titled, Neurological Evaluation indicated that neurological evaluations will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluations will be performed: -Every 15 min times 2 hours then -Every 30 minutes times 2 hours then -Every 60 minutes times 4 hours then -Every 8 hours until 72 hours has lapsed. The purpose of neurological assessments was to monitor for neurological compromise. The facility policy dated 10/24/22 and titled, Person Centered Care Plan that the purpose was to attain the patient's highest practical physical, mental, and psychological wellbeing. NJAC 8:39-27.1(a)