**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 03/22/23 at 11:02 AM, Surveyor #2 observed Resident #38 lying flat on his/her back with the head of the bed slightly elevated. The resident was lying on a pressure relieving mattress. On 03/23/23 at 10:08 AM, Surveyor #2 observed Resident #38 lying in bed, flat on his/her back and was sleeping. There was cushioning observed under the resident's legs. On 03/23/23 at 12:18 PM, Surveyor #2 observed Resident #38 lying in bed flat on his/her back with cushioning under the resident's legs and in the same position as observed at 10:08 AM. Surveyor #2 observed there had been no repositioning or turning for the resident. On 03/27/23 at 8:51 AM, Surveyor #2 observed Resident #38 lying in bed flat on his/her back with cushioning under the resident's legs. On 03/27/23 at 9:55 AM, Surveyor #2 observed Resident #38 lying flat on his/her back in bed. The television was on. The surveyor observed cushioning under the resident's legs. On 03/27/23 at 10:30 AM, Surveyor #2 observed Resident #38 lying flat on his/her back in bed with cushioning under the resident's legs. On 03/27/23 at 10:54 AM, Surveyor #2 observed Resident #38 in the same position on his/her back as initially observed at 8:51 AM. At that time, the resident's CNA was in the hallway. During an interview with Surveyor #2, the CNA stated the resident was on hospice and required total care. The CNA stated she would do everything for the resident because the resident was unable to do anything for him/herself. The CNA stated the staff would have to change, wash, and clean up the resident. The resident remained in the same position for approximately two hours, and had not been turned or repositioned. Surveyor #2 reviewed Resident #38's hybrid medical records which revealed the resident had been admitted with diagnoses which included but were not limited to; unspecified dementia with behaviors, hypertensive (elevated blood pressure) heart disease with heart failure, and Type 2 diabetes mellitus. A review of the most recent Quarterly MDS dated [DATE], included but was not limited to: Section B, rarely/never understood and rarely/never understands. Section C, a BIMS was not conducted related to the resident rarely/never understood. Section G, functional status revealed the resident had total dependence on staff for Activities of Daily Living (ADL). Section H revealed the resident was always incontinent of urine and bowels. Section O revealed Resident #38 had been on hospice care while a resident. The facility provided, Plan of Care-Current, dated 3/30/23, included but was not limited to: a focus area of ADL self-care deficit and at risk for development of contractures due to impaired mobility; Intervention dated 5/18/22, turn and reposition q (every) 2 hours and prn (as needed), keep off body prominences, if able, use pillows to reposition; provide total assistance with ADL including bed mobility, toileting needs. A review of the [NAME] Summary (a care guide) revealed the resident was dependent on staff for care; to turn and reposition q (every) 2 hours, pillows to offload pressure areas; On hospice care. On 03/29/23 at 10:03 AM, Surveyor #2 observed Resident #38 lying in bed on his/her back with cushioning under the resident's legs. On 03/29/23 at 12:05 PM, Surveyor #2 observed Resident #38 in bed lying on his/her back with cushioning under the resident's legs. Surveyor #2 observed that no repositioning or turning had been done for over two hours. On 03/30/23 at 8:44 AM, Surveyor #2 observed Resident #38 lying flat on his/her back with cushioning under the resident's legs. On 03/30/23 at 10:45 AM, Surveyor #2 observed Resident #38 lying in bed flat on his/her back with cushioning under the resident's legs. Surveyor #2 observed that no turning or repositioning had been done for two hours. On 03/30/23 at 11:07 AM, Surveyor #2 observed Resident #2 lying flat on his/her back with cushioning under his/her legs. The CNA was observed in a resident room across from Resident #38's room, hanging up clothes. On 03/30/23 at 11:09 AM, during an interview with the surveyor, the CNA stated she would use the computer [NAME] to see what she would need to do for residents. The CNA showed Surveyor #2 the [NAME] for Resident #38 on the computer. The [NAME] indicated the resident was to be turned and repositioned every 2 hours. Surveyor #2 asked the CNA what repositioning and turning the resident involved. The CNA stated, we go one side, back, and other side. When asked how the CNA knew what the last position was, the CNA responded, I've been here all morning. Surveyor #2 and the CNA went to Resident #38's room. The CNA acknowledged the resident was positioned on his/her back. The CNA showed the surveyor what she would do to reposition a resident. The CNA lifted the two pads that were under the resident and stated she would put a pillow under there to keep the resident on their side. Surveyor #2 observed no other pillows in the room except the one under the resident's head and legs. The CNA stated a resident would be repositioned and turned to avoid pressure ulcers. When asked why Resident #38 had not been turned or repositioned, the CNA stated the hospice aide had been there about 9:00 AM and it was not time to reposition the resident. On 03/30/23 at 11:21 AM, during an interview with Surveyor #2, the Registered Nurse (RN) showed Surveyor #2 the book that the hospice aides use to sign in which revealed the hospice aide had been there at 7:45 AM. The RN stated a resident in bed should be repositioned and turned every 2 hours. She stated the CNA should be documenting the turning and repositioning in the computer. The RN stated, we want to prevent skin breakdown as the reason for turning and repositioning resident who were dependent on staff. On 03/30/23 at 11:32 AM, during an interview with Surveyor #2, the DON stated that bed bound residents should be repositioned every two hours to avoid skin breakdown. A review of the facility provided, CNA Flow Sheet, dated 2/1/23 to 2/28/23, revealed an area for turning/repositioning. Did you turn the resident Q2H [every two hours]? N (night), D (day), P (PRN-as needed). The dates of 2/1 through 2/15 revealed no documentation to indicate the resident had been turned or repositioned every 2 hours or at all on the night shift, day shift, or as needed. On the night shift it was documented 1 on 2/16, to indicate the resident was repositioned and turned only one time and not every 2 hours of the day. On 27 of 28 days there was no documentation to indicate that the resident was turned or repositioned on the night shift. On the day shift it was documented 1 on 2/16, 2/18, 2/20, 2/22, and 2/24, which indicated the resident was not turned and repositioned every 2 hours of the day. There was no documentation that the resident was turned and repositioned every 2 hours on the day shift on 8 of 28 days: 2/17, 2/19, 2/21, 2/23, 2/25, 2/26, 2/27, or 2/28. On the as needed area, it was documented that the resident was turned and repositioned only 1 time on 4 of the 28 days. This indicated the resident was not repositioned or turned every 2 hours of the day. A review of the facility provided, CNA Flow Sheet, dated run date 3/31/23 at 8:07 AM, revealed an area for turning/repositioning. Did you turn the resident Q2H? The night shift documented 1 on 28 of 30 dates (not including 3/31/23), and 2 on 1 of 31 dates. This indicated that the resident was not repositioned and turned every 2 hours of the day. Two of the dates, 3/4 and 3/5 had no indication that the resident had been turned or repositioned every two hours or at all. The day shift documented 1 time on 15 of 30 dates; 2 times on 5 of the 30 dates; and 3 times on 1 of the 30 dates. This indicated that the resident had not been turned or repositioned every 2 hours of the day. Nine of the dates, 3/2, 3/4, 3/5, 3/7, 3/14, 3/18, 3/19, 3/23, and 3/28 had no indication that the resident had been turned or repositioned every two hours or at all. On the as needed area, it was documented that the resident was turned and repositioned 1 time on 21 days and 2 times on one day. This indicated that the resident had not been turned and repositioned every 2 hours of the day. A review of the facility provided, Nursing Orientation for Assistive Personnel Clinical Staff C.N.A. & MHA [Mental Health Assistant], revised 1/23, included but was not limited to Pressure Injuries, preventative measures, and avoid pressure on bony prominences, turn and position q (every) 2 hours. Included in the book was a card the facility used which had turning and repositioning schedule times and positions as follows: 12 a.m. back, 2 a.m. door, 4 a.m. window, 6 a.m. door, 8 a.m. back, 10 a.m. window, noon back, 2 p.m. door, 4 p.m. window, 6 p.m. back, 8 p.m. door, and 10 p.m. window. Notes: follow above schedule when patient is in bed; otherwise directed by nurse. The turning and repositioning schedule had not been followed. The surveyor requested the facility policy regarding turning and repositioning for residents. The facility provided, Pressure Injury Prevention and Management, dated revised 8/22, included but was not limited to the responsibility of the RN, Licensed Practical Nurse (LPN), and CNA to ensure all residents in bed will be turned and repositioned every 2 hours per repositioning schedule or more often as indicated. A review of the facility provided, Certified Nursing Assistant, undated, included but was not limited to performs basic, routine duties related directly and indirectly to nursing care of patients; and assists patient with activities of daily living. A review of the facility provided, Registered Nurse, undated, included but was not limited to utilized patient care standards in clinical practice; and provides clinical supervision of LPN's, CNA's, and ancillary staff. NJAC 8:39-27.1 (a) C #NJ159085 C #NJ158716 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to follow the facility post fall procedure to ensure appropriate care was provided and there was no delay in treatment and ensure: a.) a supervisor was notified, b.) a physical assessment was completed and documented, c.) the physician was notified, and d.) the fall incident was documented in the medical record. This deficient practice occurred for 1 of 34 residents reviewed for quality of care (Resident #168) who had a history of falls, including a fall with a shoulder fracture on 11/30/21, and who sustained an unwitnessed fall when a noise was heard in Resident #168's room on 01/22/23 at 10:35 PM, and the Licensed Practical Nurse (LPN) found Resident #168 lying on the floor and transferred the resident back into bed. On 01/23/23 at 2:10 AM, Resident #168 complained of pain (approximately 4 hours later) and stated he/she had fallen out of bed and had been placed back into bed which resulted in a right distal tibia fracture that required surgical intervention on 01/24/23; and failed to d.) ensure a bed-bound resident was turned and repositioned every two hours per the resident centered Care Plan (CP). This deficient practice occurred for 1 of 34 residents reviewed for quality of care, and for 1 of 2 residents reviewed (Resident #38) for hospice care and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) On 03/27/23 at 11:35 AM, Surveyor #1 observed Resident #168, sitting in the dayroom, appeared well groomed, and responded to the surveyor's greetings. Surveyor #1 reviewed Resident #168's electronic medical record which revealed in the Care Area Assessment Documentation that Resident #168 was triggered for Activities of Daily Living, (ADL), secondary to decline in overall ADL functions due to a recent post right ankle Open Reduction Internal Fixation (ORIF) on 02/03/23, status post fall with fracture of the right tibia. According to the admission face sheet, Resident #168 was admitted to the facility with diagnoses which included but were not limited to, other fracture of lower end of right tibia, major depressive disorder, and unspecified schizophrenia. The Significant Change Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care, dated 02/05/23, reflected that Resident #168 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of moderate cognitive impairment. On 01/22/23, Resident #168 had an unwitnessed fall in their room. According to the facility provided incident report, Resident #168 was found on the floor next to the bedside. Resident #168 did not have any visible injuries. However, several hours later, Resident #168 complained of pain on the right leg. Upon assessment, Resident #168 was noted to have soft tissue swelling and pain. An X-ray was ordered and performed on 01/23/23 at 8:32 AM. The results were forwarded to the facility on [DATE] at 10:29 AM and revealed oblique comminuted fracture of the distal tibia diaphysis. Resident #168 was transferred to the hospital and underwent surgical intervention to repair the fracture. Review of Resident #168 electronic progress notes dated 01/22/23, did not contain any documentation regarding the fall that occurred on 01/22/23. A nursing progress note dated 01/23/23 at 2:00 AM, revealed the following documentation, Resident #168, c/o [complained of] pain to right leg to the CNA (Certified Nurse Aide). The CNA informed the nurse. The nurse went and assessed the resident and noted that the resident right shin was swollen. Resident #168 informed the nurse that he/she sustained a fall during the 3:00 PM-11:00 PM shift. The nurse alerted the Assistant Director of Nursing (ADON) on duty who came and assessed the resident. Resident #168 stated that he/she sustained a fall after dinner and the LPN assisted him/her into bed. Further review of Resident #168's medical record progress notes dated 01/23/23 timed at 11:58 AM, documented severe pain to the leg, Motrin (a non-steroid analgesic) 600 milligram (mg) administered for pain. The physician ordered to transfer Resident #168 to the hospital. A late entry dated 01/23/22 timed at 10:50 PM, revealed that Resident #168 was found on the floor the evening of 01/22/23 and was assisted to bed by a staff member. There was no evidence of a documented assessment. There were no progress notes to indicate that the physician was called and informed of the fall. The facility's post fall procedure was not available for review. On 03/28/23 at 9:07 AM, Surveyor #1 observed Resident #168, in the room sitting in a wheelchair next to the bed. An interview with the resident revealed that he/she fell while attempting to go to the bathroom. The resident stated the floor was slippery. The surveyor asked the resident how he/she managed to go back to bed, Resident #168 stated, he picked me up, but was unable to recall the name of the staff. On 03/28/23 at 11:30 AM, Surveyor #1 requested the fall investigation for review. According to the Occurrence Report dated 01/23/23, the resident reported the fall at 2:15 AM. Resident #168 informed the ADON that he/she fell after dinner and before 11:00 PM. The fall was not entered on the 24-hour report or in the clinical record to alert the incoming shift to monitor the resident during the night. On 03/28/23 at 12:21 PM, Surveyor #1 interviewed the LPN on duty regarding staffing on the floor. The LPN stated that staffing was very bad on the weekend. The LPN stated that sometimes there were only three CNAs for 56 residents and stated, we try to do our best. On 03/28/26 at 12:26 PM, Surveyor #1 then inquired about the facility post fall protocol. The LPN stated that the process was to ensure no fall recurrence. The LPN stated after a fall a resident assessment must be completed, the physician and the nursing supervisor must be notified. An incident report must be generated. The LPN further added it should be done immediately. You do not want any delay in treatment. The family or the resident's representative were to be made aware also. On 03/29/23 at 10:38 AM, during a second interview with the LPN, she stated that at the end of the shift, a unit report was written regarding day-to-day activities of the unit and a detailed report was entered on the computer. Surveyor #1 requested the detailed report for 01/22/23 for the 3:00 PM-11:00 PM shift, however, there was no detailed report available for review. On 03/29/23 at 11:39 AM, Surveyor #1 conducted a telephone interview with the LPN who worked the 3:00 PM - 11:00 PM shift on 01/22/23, the actual day of the fall. The LPN stated that he heard some movements emerging from Resident #168's room. He then entered the room and observed Resident #168 on the floor, and there was also water on the floor. Resident #168 stated that he/she wanted to go the bathroom and he/she fell. The LPN confirmed that he assisted Resident #168 back to bed. When asked if he assisted Resident #168 to the bathroom, he stated, No. The surveyor asked the LPN if he could recall the time of the incident, the nurse stated it was between 9:00 PM-10:00 PM. The nurse did not inform the physician nor the resident's representative of the fall. The LPN did not inform the ADON on duty that Resident #168 had a fall and needed to be assessed. During the telephone interview, the LPN did not indicate that he forgot to log the fall on the 24 hours report, or in the resident clinical record. The LPN stated clearly to the surveyor, I did not do it. The surveyor then asked the LPN if he was familiar with the facility's policy and protocol post fall, and he stated, Yes. The LPN went on to state the resident must be assessed, an incident report must be initiated, and the physician and the family are to be notified. The LPN further stated that it was negligence on his part not to report or discuss the fall with the ADON on duty that evening. On 03/29/23 at 12:11 PM, Surveyor #1 interviewed the Director of Nursing (DON) regarding the above incident. The DON revealed that she was aware of the incident. The DON stated that the LPN did not follow their protocol. The DON stated that the incident was not reported to DOH (Department of Health). The DON stated, My expectation is to ensure that our residents were safe. For staff, my expectation was that they follow the policy. All policies were reviewed during orientation and as necessary if there is a change in the policy. All policies could be accessed on the computer. The LPN did not follow the facility's policy. The DON stated that she had an open-door policy and staff were free to discuss any concerns. On 03/29/23 at 12:30 PM, Surveyor #1 interviewed the ADON who conducted the 01/22/23 fall investigation. The ADON revealed that the Fall Team committee investigated all falls for Long Term Care. The ADON stated normally all falls must be reported and entered on the 24-hour report. The Unit Managers must report all falls. Disciplines which participated in the Fall Committee included nursing, activities, and Physical Therapy (PT). All must interview the resident. The resident's clinical record was reviewed prior to interview. The ADON stated that the facility had daily meetings which discuss residents that were at risk or needed additional monitoring. The ADON stated that Resident #168 had a fall on 01/22/23, during the evening shift after dinner. The resident stated that he/she was trying to get out of bed to the bathroom, and he/she hit his/her leg. The ADON stated staff were looking for the incident report and could not locate the occurrence report that should have been initiated on 01/22/23. An investigation was started on 01/23/23. All CNAs who worked that shift were interviewed and were not aware of the fall. The ADON and the UM interviewed the LPN who worked that evening. The LPN stated that he was monitoring another resident next door when he heard noises in Resident #168's room. He entered the room and observed Resident #168 on the floor. The LPN did not observe a visible injury and then assisted the resident back to bed. The LPN was asked to elaborate on the protocol to follow a fall. He stated that he was aware of the need to write an incident report, notify the physician, notify the family and report to the next shift. The LPN stated he was sorry and received one day suspension and was reeducated verbally. On 03/30/23 at 8:54 AM, Surveyor #1 obtained and reviewed the LPN's employee file. On 01/31/23, the LPN received one day suspension for the 01/22/23 incident. On 03/30/23 at 9:01 AM, during an interview with the UM regarding the fall, she stated that she interviewed the LPN regarding the fall. The LPN stated that he was focused on another patient. The UM stated that the LPN did not mention that he forgot to report the fall. The UM stated that the LPN was reeducated. On 03/31/23 at 9:11 AM, Surveyor #1 interviewed the Administrator (LNHA) regarding the fall incident. The LNHA revealed that she was made aware that Resident #168 reported that he/she fell and was injured. The evening shift nurse did not report the incident. The incident should have been reported to the next shift for follow up. Any fall must be reported. The LNHA stated that they identified the event as an issue before the survey. The administrator added, As an Administrator, I expected all staff to follow the facility's policies. Interventions should have been put to place immediately. A review of the facility's policy titled,Policy/Procedure: Occurrences-Assessment, Reporting and Intervention, last revised 12/21, included the following: Policy: The facility will maintain systems for reporting, patient/resident, staff, visitor, and property occurrences or potential occurrences (near misses). This date will be used to monitor, evaluate, and trend occurrences to identify opportunities for improvement in patient/resident care and overall safety in the medical center. Occurrence: An occurrence is defined as any incident that is not consistent with routine hospital operation or patient/resident care or any circumstance that threatens physical safety and well-being regardless of whether an actual injury is involved. Responsibility The employee discovering the incident is responsible for completing the occurrence report and informing his/her immediate supervisor of the event. The supervisor will begin an initial investigation of the occurrence and forwarded to the Department/Division VP (Vice President). The VP/designee of the area is responsible to determine if additional action is required and for overseeing a complete and thorough investigation with corrective action plan when applicable. Under Guidelines for completing an Occurrence Report, the following were entered: An Occurrence Report should be completed ASAP [as soon as possible], while the facts are still fresh in everyone's mind. Include essential information, including complete names of all witnesses. Describe only what you saw and heard, and the actions taken on the scene, for example, unless you saw the patient fall, document Patient found on the floor . The Falls Prevention and Management Policy, Revised 12/2021 revealed a Post-Fall Algorithm: Fall; Perform Physical Assessment; Notify Physician, Supervisor; Patient/Resident's Next of Kin; Document Occurrence in Medical Record, Complete Occurrence Report; Perform Post Fall Huddle or Fall Team Meeting as per Divisional Protocol; Review and Update Care Plan Conduct a Fall Re-Assessment as per Policy & Procedure; Continue to re-evaluate patient for fall risk and follow division protocols.