**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to immediately inform the physician and resident representative after a significant change in condition for 1 of 6 Residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's Physician and Responsible Party after Resident #1 had a fall with injuries that resulted in a brain hematoma with a midline shift in which Resident died due to fall. The facility failed to notify Resident #1's Physician and Responsible Party after Resident #1 had a fall resulting in his head hitting the floor and sustaining a laceration to the right eyebrow/cheek. This failure could place residents at risk by causing a delay in necessary medical intervention, not allowing physician and families to be aware of any changing conditions and/or death. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20 PM. While the immediate jeopardy was removed on [DATE] at 6:00 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Findings include: Record Review of Resident #1's clinical record on revealed he admitted on [DATE], was [AGE] years of age with the following diagnoses: dysarthria following cerebral infarction (slurred speech after a stroke), muscle weakness, difficulty in walking (not elsewhere classified), occlusion and stenosis of bilateral carotid arteries (blocked or narrowing of the large arteries), benign prostatic hyperplasia (prostate gland enlargement) without lower urinary tract symptoms, hypothyroidism (overactive thyroid), hyperlipidemia (high cholesterol), other insomnia, essential (primary) hypertension (high blood pressure). Record review of an admission MDS assessment dated [DATE], documented that Resident #1 had clear speech, was usually understood but had some difficulty communicating some words or finishing thoughts, sometimes understands and able to respond to simple, direct communication only. Brief Interview for Mental Status (BIMS) was a 3 out of 15 indicating he had severely impaired cognition. He required only supervision and set up help only for walking. He required supervision of one staff physical assist for transfer, bed mobility, eating, and toileting. He needed extensive assist of one staff for dressing and hygiene. Record Review of Resident #1's care plan, dated [DATE] revealed he was identified as a fall risk with interventions that include Resident #1's call light is within reach, and ensure the resident is wearing appropriate footwear, the resident needs prompt response to all requests. Record Review of Resident #1's Progress notes dated [DATE], revealed he was a fall risk and has had 1-2 falls in the past 3 months prior to admission and that his fall risk score is a 10.0 indicating he was high risk. Record Review of Resident # 1's Physician's orders dated [DATE] revealed Resident #1 was taking Clopidogrel 75 MG tablet once a day for Acute Cerebrovascular insufficiency (obstruction of arteries to the brain). Also, on [DATE] revealed Resident was taking Aspirin low dose 81 mg tablet daily for cerebral infarction (stroke). Record Review of Facility Fall Incident Log on [DATE] at 1:50 PM revealed Resident #1 had 3 falls since admission. Resident #1experienced 2 falls on [DATE]rd, without injury and then one on [DATE] with injury to head and wrist. Record Review of the facility's Provider Investigation Report dated [DATE] and revealed Resident #1 had a fall on [DATE] at 1:40 AM when Resident was standing in room by bedside with CNA B assisting to change him, he lost his balance and fell to the floor hitting his head. Resident sustained a laceration approximately 1 inch to right eyebrow/cheek and skin tear to right wrist. Resident was assessed by RN A and Resident was responding in usual manner at time of initial assessment - area was cleansed, and dressing applied to right side of head. Neuro protocol was performed by RN A. CNA B sat outside resident's room to monitor as well. At approximately 5:00 AM resident had a change in condition. Primary Care Physician and EMS were then notified. Patient was taken to Emergency Department where CT results showed a brain hematoma (brain bleed) with midline shift. He was placed on comfort measures at hospital, where he expired later that afternoon. During a phone interview with Resident #1's POA on [DATE] at 11:40 AM, she stated that she was not called when Resident #1 fell and that she didn't get a call from the facility until he was unresponsive which was around 5:00 AM on [DATE]. POA was informed at that time that Resident #1 was being transported to hospital by ambulance for further evaluation. During a phone interview with RN A on [DATE] at 1:20 PM, she stated that Resident #1 fell at 1:40 AM. CNA B was helping to change Resident #1's brief/pull up, standing beside the bed and he lost his balance and fell hitting his head on a bedside table. She stated when she got to his room, he was laying on his right side and a pool of blood was on the floor of about 6 inches in diameter. She stated Resident was responding and helped them get him off the floor and back into bed. She stated she started wound care on his right temple area and his right wrist and got the head injury bleeding stopped and started neuro checks and vitals. Neuro checks were performed every 15 minutes for the first hour after injury, every 30 minutes for the next hour, every hour until his vitals changed. She went on to state that he wasn't complaining of any pain. RN A stated that since she got the bleeding stopped on Resident #1's head injury, she felt it was ok not to call the physician or EMS. Resident #1 remained stable until around 5AM but then his blood pressure went up and he became lethargic and stopped responding. When asked if physician was called immediately after Resident #1's fall, she stated no, he was called around 5:00 AM. When asked why she waited until 5:00 AM to call the physician, she said, You've got a point. In an interview on [DATE] at 2:18 PM with the DON about Resident #1's fall, DON stated that it was at the discretion of RN A about when to call the physician. When asked what medications Resident #1 was taking, since EHR wasn't allowing surveyors to see all aspects of Resident's chart, she went to Resident #1's patient file and showed surveyor that Resident was taking a blood thinner which was the generic brand of Plavix and an Aspirin, each one time per day. During a phone interview with the Resident #1's primary care physician on [DATE] at 2:50 PM he revealed that he was not called about Resident #1's fall on [DATE] until approximately 6AM. He stated that he told RN A to call EMS immediately and get him to the hospital and he then stated that RN A did not follow protocol, that he was to be notified immediately after any fall. He went on to state had he been notified immediately after the fall; he would have sent Resident #1 immediately to the ER for a CT scan of his brain. He stated immediacy could have made a difference in what happened to Resident #1. Record Review of facility policy Head Injury dated [DATE] stated: It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury. Policy goes on to state that assessment will include: vital signs, general condition and appearance, neurological evaluation - checking for changes in behavior, cognition, dizziness, nausea, physical functioning, slurred speech, Pain assessment. Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs. Notify physician and follow order for care: provide information from physical assessment, describe how injury occurred and how situation has been managed so far, report any recent medication changes or use of anticoagulant/antiplatelet medications, any recent lab or diagnostic test results. On [DATE] at 4:20 PM the Administrator, DON, and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on [DATE] at 9:18 AM. It is alleged that the facility failed to notify Resident #1's Physician and Responsible Party after resident #1 had a fall with injuries. Facility Plan of Removal states: The DON implemented disciplinary action with licensed nurse who was aware of significant change but did not report it to the physician. Additional Relias training was assigned and will be completed by [DATE]. All Licensed nurses were educated by DON on change of condition and physician notification regulations, as well as facility policy and procedure. Nurse Aides were educated by the DON on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policies and procedure, accordingly in orientation human resources/designee. Notification of Changes Policy reviewed and updated on [DATE]. The DON implemented a Quality Assurance Performance Improvement (QAPI) performance improvement project (PIP) with the focus on physician notification of significant changes. The PIP resulted in implementation of daily DON/designee audits of the 24-hr report to monitor for changes in the resident condition. The DON/designee will also complete chart audits/health documentation assessment as follows: Three residents weekly for four weeks then; Two residents weekly for two weeks then; Two residents a month for two months. Will Review PIP results at monthly QAPI meeting X 90 days. Monitoring of the Plan of Removal Included: In an interview on [DATE] at 12:16 PM, the DON stated that RN A will be required to take three trainings before returning to work and was written up. RN A will be required to take Basic injury assessment, Adverse incident management and preventing, recognizing, and reporting abuse. The DON stated that in-services were conducted on [DATE] educating the staff on change of condition, physician notification regulation as well as facility policy and procedures. The DON stated that she revised the policy Notification of changes on [DATE] and it was attached to the POR. DON said that all staff will be given a paper copy of the revised policy. The DON also stated that she implemented a Quality Assurance Performance Improvement (QAPI) which focused on physician notification of significant changes. The Performance Improvement Plan (PIP) resulted in implementing a daily audit to monitor changes in resident conditions. The DON stated she and the ADON will complete the assessment audits and the audits will be documented in their EHR. The DON stated that she and the ADON have completed one audit to date. The DON also stated that after she sent the POR, she decided that she would require all licensed nurses would take Adverse Incident Management training as well. During interviews with facility staff conducted on [DATE] from 12:35 PM to 5:55PM, 47 of 47 staff (1 Admin, 1 DON, 1 ADON, 1 Dietary Manager, 2 Cooks, 4 Dietary Staff, 1 Activity Director, 1 Activity Director Assistant, 1 Social Worker, 5 Housekeepers/Laundry, 1 Maintenance Supervisor, 1 Van driver/maintenance, 1 Housekeeping Assistant, 3 RNs, 7 LVNs, 12 CNAs, 1 CMA, 2 Human Resources) members verified that they had been in serviced on when to notify physician and family and had received Notification of Changes training and Abuse/neglect training on [DATE]. Record Review on [DATE] of new policy Notification of Changes revised on [DATE] revealed facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Accidents, resulting in injury, where falls involve hitting head and on blood thinners such as Plavix, Eliquis, Xarelto sent to ER for further evaluation. Potential to require Physician intervention. Significant change in resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status including life threatening conditions or clinical complications. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20PM. While the Immediate Jeopardy was removed on [DATE] at 6:00PM, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record reviews, the facility failed to ensure that residents are free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect. The facility failed to ensure Resident #1 was assessed after a fall on [DATE] resulting in his head hitting the floor and sustaining a laceration to the right eyebrow/cheek . The facility failed to monitor the resident after the fall and after approximately 3.5 hrs. a change in condition was noted resulting in the resident being transferred to the hospital where he expired due to a brain bleed. This failure could place residents at risk of substandard or delay of care, physical harm, or death. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20 PM. Although the IJ was removed on [DATE] at 6:00 PM the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. The Plan of removal (POR) of IJ will be included in the findings. Findings included: Record Review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Dysarthria following Cerebral Infarction (slurred speech after a stroke), muscle weakness, difficulty in walking, and hypothyroidism(overactive thyroid). Record Review of Resident #1's admission MDS dated [DATE] revealed that Resident #1 had a BIMS (Brief Interview for Mental Status) score of 3 out of 15 which indicated he had severe cognitive impairment. MDS also revealed that Resident #1 required only supervision and set up help only for walking. He required supervision of one staff physical assist for transfer, bed mobility, eating, and toileting. He needed extensive assist of one staff for dressing and hygiene. Record Review of Resident #1's care plan dated [DATE] revealed that Resident #1 was at risk for falls due to dysarthria and CVA (Cerebrovascular accident). He also had a communication problem related to dysarthria and Cerebrovascular accident(stroke). Interventions were to monitor/document for physical/nonverbal indicators of discomfort, or distress and follow up as needed. Monitor/document and report any changes in ability to communicate. Record Review of physician's orders dated [DATE] revealed that Resident #1 was taking Clopidogrel 75 mg one time a day related to Acute Cerebrovascular (obstruction of arteries of the brain) insufficiency. Resident #1 was also taking Aspirin low dose 1 tablet daily for Cerebral Infarction (stroke). Record Review of Resident #1's progress notes dated [DATE] revealed he was a fall risk and had 1-2 falls in the past three months prior to admission. Record Review of Facility Fall incident Log revealed that Resident #1 had three falls since admission, [DATE], Resident #1 had two falls with no injuries and [DATE] one fall with head injury. Record Review of Resident #1's Neurological Flow sheet dated [DATE] revealed that RN A conducted neuro checks and vitals on Resident #1 from the time of the incident until he was transported to the hospital at 5:45 AM. The flow sheet revealed no pain assessment documentation for Resident #1. Record Review of Fall assessment dated [DATE] at 1:40 AM revealed no documentation of pain assessed at the time of the incident. Record Review of the facility investigation report completed by DON revealed that Resident #1's fall occurred on [DATE] at or about 1:40 AM. The investigation report revealed that the resident was standing in his room at his bedside while CNA B was assisting him in changing his brief. Resident #1 lost his balance falling hitting his head. Resident sustained a 1-inch laceration to the right brow/cheek area and a skin tear to the right wrist. Investigation revealed that the resident had a change of condition at approximately 5:00 AM and was transported to the hospital via ambulance. Resident #1 died at 5:18 PM at the hospital. Record Review of Resident #1's medical record from emergency room on [DATE] revealed that the transport for the resident was delayed due to resident coughing up large amounts of blood, Resident #1 was placed on a Laryngeal Mask Airway (temporary method to maintain an open airway) Assessment indicated that Resident #1 was in an altered state of consciousness, secondary to a brain hematoma with midline shift.(brain bleed with a shift) Resident #1 expired on [DATE] at 5:18 PM, cause of death was a fall hitting his right skull causing a brain bleed and midline shift of the brain which was fatal. During an interview/observation on [DATE] at 8:45 AM, the ADON stated that a pain assessment should have been completed on Resident #1 and thought that the pain assessment was done on the same document as the Neurological Flow Sheet but wasn't for sure. Because the ADON wasn't for sure, she accessed the facility's EHR to show surveyor where the pain assessment would be documented. The ADON told surveyor that she wasn't sure if she should be showing this to surveyor but then pulled up an anonymous resident that she had completed a pain assessment on in the past to show surveyor where it would be documented. During a telephone interview on [DATE] at 10:58 AM, RN A stated she was called into the room by CNA B on [DATE] at approximately 1:40 AM to assist with Resident #1 as he had fallen. RN A stated she observed Resident #1 on the floor on his right side and a 6-inch diameter pool of blood near the resident. RN A stated she did wound care on his head injury and wrist area. RN A stated she put a dressing on the wound and got the bleeding stopped. RN A stated she started the neuro and vital checks on the resident after she got him into bed. RN A stated that pain assessments are done along with the neuro checks but the resident wasn't complaining of pain. RN A stated she did not contact the physician immediately due to Resident #1 being stable. RN A stated that the physician was notified on or about 5:00 AM when the resident's blood pressure elevated, and he became lethargic and stopped responding. During an interview/observation on [DATE] at 11:05 AM, the DON accessed Resident's #1 fall assessment dated [DATE] via the facility's EHR but could not find where the pain assessments were conducted on Resident #1 after his fall on [DATE]. The DON showed surveyor the fall assessment document and showed where the pain assessment should be documented, but the area was grayed out and nothing was in the assessment about pain. The DON stated that the pain assessment was supposed to be done during neuro/vital check but was not documented so she is not sure if it was completed. During an interview on [DATE] at 11:15 AM, the ADM stated that falls happen and sometimes fall mats don't work as they also could be considered a fall hazard because residents trip over them. The ADM stated he was not familiar with the resident but had seen him walk around the facility with his walker. The ADM was not sure of what assessments were completed on the resident at the time of his fall. Record Review on [DATE] of Abuse, Neglect and Exploitation Policy revised on [DATE] revealed that neglect is the failure of the facility, its employees, or service provers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriate of resident property and exploitation that achieves: Assuring an assessment of the resources needed to provide care to all residents is included in the facility assessment. Record Review on [DATE] of facility policy Head Injury policy revised on [DATE] revealed in part It is the policy of this facility to report potential head injuries to the physician and implement intervention to prevent further injury. Policy explanation and compliance guidelines a. Vital signs b. General condition and appearance c. Neurological evaluation d. Evaluation of the head, eyes, ears, and nose for significant change in vision, hearing, smell or bleeding. e. Any injuries to head, neck, eyes, or face including lacerations, abrasion or bruising. f. Pain assessment. On [DATE] at 4:20 PM the Administrator, DON, and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. On [DATE] at 9:18 AM the Facility's Plan of Removal was accepted. It was alleged that the facility failed to ensure that Resident #1 was being assessed for pain after a fall that resulted in a head injury that ultimately resulted in death. The facility's plan of Removal stated as follows: Actions to Prevent Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. o The DON implemented disciplinary action with licensed nurse who was aware of significant change but did not report it to the physician. o Additional Relias training was assigned and will be completed by [DATE]. o All Licensed nurses were educated by DON on change of condition and physician notification regulations, as well as facility policy and procedure. o Nurse Aides were educated by the DON on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. o New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policies and procedure, accordingly in orientation human resources/designee. o Notification of Changes Policy reviewed and updated on [DATE]. o The DON implemented a Quality Assurance Performance Improvement (QAPI) performance improvement project (PIP) with the focus on physician notification of significant changes. o The PIP resulted in implementation of daily DON/designee audits of the 24-hr report to monitor for changes in the resident condition. o The DON/designee will also complete chart audits/health documentation assessment as follows: o Three residents weekly for four weeks then; o Two residents weekly for two weeks then; o Two residents a month for two months o Will Review PIP results at monthly QAPI meeting X 90 days Monitoring the plan of Removal Included: During an interview on [DATE] at 12:16 PM, DON stated that RN A will be required to take three trainings before returning to work and was written up. RN A will be required to take Basic injury assessment, Adverse incident management and Preventing, recognizing, and reporting abuse. DON stated that in-services were conducted on [DATE] educating the staff on change of condition, physician notification regulation as well as facility policy and procedures. DON stated that she revised the policy Notification of changes on [DATE] and was attached to the POR. DON said that all staff will be given a paper copy of the revised policy. DON also stated that she implemented a Quality Assurance Performance Improvement (QAPI) which focused on physician notification of significant changes. The Performance Improvement Plan (PIP) resulted in implementing a daily audit to monitor changes in resident conditions. The DON stated she and the ADON will complete the assessment audits and the audits will be documented in their EHR. DON stated that she and the ADON have completed one audit to date. The DON also stated that after she sent the POR, she decided that she would require all licensed nurses would take Adverse Incident Management training as well. During interviews on [DATE] from 12:35 PM to 5:50 PM 47 of 47 staff (1 ADM, 1 DON, 1 ADON, 1 Dietary Manager, 2 Cooks, 4 Dietary Staff, 1 Activity Director, 1 Activity Director Assistant, 1 Social Worker, 5 Housekeepers/Laundry, 1 Maintenance Supervisor, 1 Van driver/maintenance, 1 Housekeeping Assistant, 3 RNs, 7 LVNs, 12 CNAs, 1 CMA, 2 Human resources) members verified that they received training on the new policy Notification of Changes and ANE training on [DATE]. Record Review on [DATE] of new policy Notification of Changes revised on [DATE] revealed in part the facility promptly inform the resident physician where there is a change requiring notification. The policy also stated accidents resulting in an injury, falls involving resident hitting head and on blood thinners send to ER for further evaluation. An Immediate Jeopardy was identified on [DATE] at 4:20 PM. While the Immediate Jeopardy was removed on [DATE] at 6:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.