**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for one (Resident #1) of seven residents reviewed for change in condition. The facility failed to notify the NP immediately by phone call when Resident #1 was found on the floor holding his head and appeared confused after an unwitnessed fall. Resident #1 was sent to the hospital approximately six hours later and admitted to the ICU with a diagnosis of subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). This failure placed residents at risk of harm, injuries, and delayed emergency services. An IJ was identified on 3/27/2025. The IJ template was provided to the facility on 3/27/2025 at 2:33 p.m. While the IJ was removed on 3/29/2025, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm that was not immediate jeopardy because all staff had not been trained on 3/29/2025. This failure placed residents at risk of harm, injuries, and delayed emergency services. Findings included: Record review of Resident #1's face sheet, dated 3/18/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 diagnoses were not included. Record review of Resident #1's physician progress notes, dated 3/19/2025 revealed the following diagnoses: Alzheimer (memory loss), frequent falls, abnormal gait, seizures, atrial fibrillation (irregular and often very rapid heart rhythm), and insomnia (inability to fall asleep or stay asleep). Record review of Resident #1's care plan, revised on 3/12/2025, revealed the following in part: Category : 11 - Falls. Problem: [Resident #1] has risk for falls related to unsteady gait, disease processes. Goal: [Resident #1] will have no fall related injuries while in the health center through the next 30 days. Seek PT/OT evaluation and treat as ordered and follow recommendations. Keep floor .clean, dry and free of clutter .Reinforce safety precautions with resident . Record review of Resident #1's nursing notes written by RN A, dated 3/15/2025, revealed the following: During my midnight rounding, this writer heard a voice calling out for help, on getting down the hall-way, Patient [Resident #1] was noted on the floor in a semi-Fowler_position on the right side of his bed beside the window holding his head. He was asked what happened and he said I got off the bed and fell help me. When asked whether he [i.e. hit] his head anywhere? Is any part of the body hurting? He was not responding to the questions. He simply stretched out his hand asking to be picked up. No skin break down, swelling nor bruising noted. This writer waited for the CNAs to get mechanical lift. [Resident #1] was assisted back in bed, incontinence care was provided. Vitals: BP 144/88, P 91, T97.6, R 16, O2 sat 96% on R.A. As the writer wants to step out of the room, patient started screaming don't go and was attempting to get out of bed. This writer instructed the aid to sit with the patient, deem [i.e. dim] the light in the room since he is more calm having a company. Checked back after 15 mins for another set of vitals, patient was calm and resting in bed. 10 mins after, the aid told me patient was sleeping. Monitored him throughout the night, no fever, no sign of acute distress noted. Bed in the lowest position, floor mat placed on both sides of the bed, call light within reach. NP notified, she ordered that the patient be sent to the ER for scan. Left voice note for the responsible party as no one was picking the call. Last set of vitals: BP 127/84, P88, T97.8, O2 sat 97% on R.A . Record review of Resident #1's Incident Report dated 3/15/2025 revealed the following (hand written by RN A): Incident Category: Fall without injury. Severity: No injury. Location of incident: Room. Describe the incident: [Resident #1] had an unwitnessed fall, was seen in a semi- Fowler position (individual lies on their back on a bed, with the head of the bed elevated between 30-45 degrees, and the legs of the patient can be either straight or bent at the knees) on the left side of bed beside the window . Resident Description: Per [Resident #1], I got off the bed and fell. Witnessed: Not applicable. Staff Action at Time of Incident: [Resident #1] was assessed for injury and pain, vitals were taken every 15 mins for 1 hour, [Resident #1] was assisted back in bed using mechanical lift. Monitored for any change in condition through out the shift. Neuro/Vital Stats: 1. BP 144/88 P 91 T 97.6 R 16 96% on R.A 2. BP 127/84 P 98 T 97.7 R 16 97% on R.A 3. BP 130/82 P 92 T 97.6 R 18 96% on R.A. 4. BP 122/84 P 98 T 97.6 R 16 97% on R.A. Notified [NP A] by mobile on 3/25/2025 at 1:07 a.m. Record review of NP A's phone text message dated 3/15/2024 at 11:58 p.m. from RN A revealed the following: Text from CNA A to NP A - Good morning, [Resident #1] [room #] was noted on the floor beside his window. He was holding his head (it was not obvious whether he hit his head on the window frame or not). When asked what happened, he was unable to explain (confused) Bp 144/88, P 91, T 97.6, R 16, O2 sat is 96% on R.A. NP A's response text message at 6:22 a.m. to CNA A - Pt needs to go to ER for scan. NP A's response text message at 6:23 a.m. to CNA A - After 10pm I need you to call for urgent changes in condition. I was asleep. Just saw this. Record review of Resident #1's hospital record dated 3/15/2025 revealed the following in part: .History of Present Illness: [Resident #1] .presented on 3/15/2025 via EMS after a fall last night at nursing home. Per report, pt fell while he was trying to get out of bed last night. In ED, pt had CT (medical imaging test) brain which showed small SAH (bleeding in the space below one of the thin layers that cover and protect the brain) in right frontotemporal and left frontal region .Neurologic: Traumatic b/I SAH, on admission, Acute post-concussive enceph (Encephalopathy - disease that affects brain structure or function), on admission .Assessment plan: His CT was positive for small amounts of right subarachnoid hemorrhage in the frontal parietal area. Patient is neurologically stable at this time with only mild confusion. He does not remember the episode. Neurosurgery team was consulted for further evaluation. His neurological exam is nonfocal (no specifics). His labs were normal. At this point I recommend an interval CT scan to confirm stability. Will plan to see him back in neurosurgery clinic for head CT in 1 month. In an interview and observation on 3/18/2025 at 1:06 p.m. (hospital), Resident #1 said he had a fall. He said he did not remember who helped him after the fall. He said he had pain at the time of the fall to his head and legs. Resident #1 was being picked up by medical transport to return to the nursing home. In an interview on 3/19/2024 at 9:38 a.m., CNA A said RN A called her to Resident #1's room. CNA A said she saw Resident #1 on the floor. CNA A said Resident #1 was aware he fell. She said he had a bowel movement that was visible. She said RN A assessed Resident #1 on the floor. CNA A said she left to go and get the mechanical lift. She said she and RN A placed Resident #1 into his bed. She said RN A instructed her to stay with Resident #1. She said Resident #1 fell asleep after approximately 20 minutes and she left the room. She said she continued to round on him every 2 hours and RN A rounded too. She said she was not aware of when RN A made the notifications to the NP. In an interview on 3/18/2024 at 6:43 p.m., RN A said she heard Resident #1 yell out for help. RN A said she went into Resident #1's room and found him on the floor near the window. She said he was holding his forehead. She said he was aware he had fell. She said she asked him if he had pain, and he did not respond. She said she did not consider his confusion a change in condition. She said she completed a head-to-toe assessment and took his vitals. She said there were no visible injuries, and his vitals were within normal range. She said she text NP A at 1:07 a.m. that Resident #1 fell. RN A said NP A did not respond. RN A said she did not make a second notification after she did not hear back from NP A. RN A said she was trained to notify the physician by phone. She said she did not make a second notification based on her nursing judgment, that Resident #1 was stable. She said NP A text her back at 6:22 a.m. to send Resident #1 out to the ER for a scan. RN A said she did not think Resident #1 was at risk of any harm because she felt he was stable. In an interview on 3/19/2025 at 9:45 a.m., NP A said she was notified by text message on 3/15/2025 at 1:07 a.m. Resident #1 had a fall. NP A was notified in the text message that Resident #1 was confused and was holding his head when he was found on the floor. She said she was on call, but asleep at 1:07 a.m. and she woke up and responded to the text message at 6:22 a.m. She said she checked and did not have a missed phone call from RN A. She said based on the details of the notification she wanted the resident to be sent out when she was notified. She said the resident was at risk of a possible head injury since he was holding his head, it was unwitnessed, and he needed to be sent out to the hospital for further evaluation. She said she preferred the resident had not been allowed to fall asleep after there was a possibility he hit his head because that could have been a change in condition. She said Resident #1 should have sent out to the ER immediately to reduce the risk of injury. In an interview on 3/19/2025 at 11:50 a.m., the DON said RN A was trained to make a phone call to notify the physician or NP on call. DON said because RN A's assessment deemed Resident #1 was stable and the resident's vitals were within normal range, she did not think there was a risk to Resident #1 health. In an interview on 3/19/2025 at 1:15 p.m., the ADMIN said she expected RN A to call the NP (on call) after a fall. She said RN A should have called her also if she did not receive a call back from NP A. She said there are postings of whom to call after an incident. She said the time that lapsed between Resident #1's fall and when he was sent out to the ER was concerning to her. She said staff were trained to call by phone to notify a physician. She said there was no risk because RN A monitored the resident and sent out to the ER after NP A responded several hours later. Record review of facility policy Assessing Falls and Their Causes (revised 10/2010) 1. If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities . 4. Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . 8. If causes of a fall cannot be readily identified and if the fall is accompanied by other signs and symptoms (e.g., confusion or lethargy), the staff and physician will consider a possible underlying acute medical cause. Review of facility policy for Accidents and Incidents-Investigating and Reporting, revised 2/2014, reflected the following in part: All accidents or incident involving residents .etc., occurring on our premises shall be investigated and reported to the Administrator . g. The time the injured person's Attending Physician was notified, as well as the time the physician responded ' his or her instructions; Review of facility policy for Chang in a resident's condition or status (revised 2/2021) reflected the following in part: Our facility promptly notifies the resident, his or her attending physician .of changes in resident's medical/mental condition and /or status . 1. The nurse will notify the resident's attending physician or physician on call . Review of the facility's call procedure Change in a resident's condition and notification, (not dated), reflected the following: Please notify the Administrator IMMEDIATELY on the following .2. Change of Condition/Incidents/Accidents/Falls .etc. - [ADMIN and ADMIN phone numbers]] An IJ was identified on 3/27/2025. The IJ template was provided to the ADMIN on 3/27/2025 at 2:33 p.m. The following Plan of Removal submitted by the facility was accepted on 3/28/2025 at 3:41 p.m.: Allegation: The facility failed notify the on-call physician in a timely manner after Resident #1 had an unwitnessed fall. 03/28/2025 Plan of Removal F580 Facility Name and Vendor ID#: [Facility Name] Impact Statement: On 03/18/2025 a complaint survey was initiated at [Facility Name]. On 03/27/2025, the facility was provided notification that the survey agency had determined that the conditions at the facility constitute an immediate jeopardy to resident health. The facility failed to obtain emergency services for unwitnessed fall for Resident #1 after a fall on 03/15/2025 that resulted in acute subarachnoid hemorrhage (blood on the surface of the brain). Resident #1 arrived at the ER approximately 6 hours after the fall. Immediate Action: Please accept this as our Plan of Removal for the Immediate Jeopardy related to F580 (Physician Notification/Residents Rights) involving failure to immediately notify the physician after a significant change in condition. Resident #1 was readmitted back to the facility on [DATE] from a local area hospital. Residents that can be affected are those who reside in the community. All facility residents were assessed for any Change in Condition. Completion date: 03/27/2025 1:1 education was immediately provided to RN A on 03/27/2025 by the Director of Nursing and Administrator. Education has been extended on 03/28/2025 to all licensed nursing staff and CNAs. Instructor: DON and ADON. Direct care staff (PRNs, new hires, from vacation) will not be allowed to render care until in-service is completed. Test questions were given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures. The topics covered were the following: 1. Policy & Procedure on Notification - Physician Notification 2. Policy & Procedure on Quality of Care - Change in a Resident's Condition o A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by the staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. o Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form in MatrixCare. Licenses nurse will follow physician order to call 911(emergency services), if applicable. 3. Updated Physician and Nurse Practitioner Notification Call Tree The updated call tree was completed on 03/27/2025. The appropriate action is to call 911 if the situation is emergent. The Physician and Nurse Practitioner Notification Call Tree is posted in all Nurses stations. All direct care staff were educated on the location and use during the in-service conducted by the Director of Nursing and the Administrator. Completion Date: 03/27/2025 Systematic Approach: Audit tools/checklists were developed to monitor timely provider notification and change-in-condition documentation. Registered and licensed nurses were educated on these audit tools. Completion date: 03/28/2025. A Notification Report audit on Change in Condition for residents in the last 30 days was reviewed and completed. These tools will be reviewed weekly for compliance. Reviewed by: Director of Nursing and Administrator The Administrator notified the Medical Director of the Immediate Jeopardy on 03/27/2025 at 3:11 p.m. An emergency QAPI meeting was held on 03/27/2025, which was inclusive of a review of our policies/protocols for Change in Condition and Physician Notification, the policies were found to be sufficient. Attendees were the following: Administrator, Medical Director, and Assistant Directors of Nursing. The Director of Nursing and the ADON were in-serviced by the Medical Director, PCP A on Change in Condition and Physician Notification on 03/27/2025. Staff in-services, to include all registered nurses, licensed clinical staff, were started on Physician Notification and all clinical staff on Changes in condition; this in-servicing will continue until all clinical staff have been trained. Staff will not be allowed to start on the floor or give care until this training has been completed. All new clinical staff will receive the in-services as part of the onboarding orientation process prior to being assigned and providing care to residents. All licensed clinical staff, will be in-serviced on Physician Notification and all clinical staff will be in-serviced on Changes in Condition. Post tests were conducted and completed to ensure understanding and competency. Completion Date: 03/27/2025 Verified by: DON All current residents were assessed to determine if there is any change in status and/or condition. The assessments were noted in the individual residents' EMR's. The physician will be made aware of any noted changes from the resident's normal baseline. This will be completed by the registered/licensed nurses and nursing leadership. Completion Date: 03/27/2025 After completion of the residents' audits, no other residents were found to be at imminent risk of having a change in condition and at their normal baseline completed 03/27/2025. Who will be responsible: Director of Nursing and ADONs Who will monitor: Administrator Monitoring of the plan of removal included the following (3/28/2025 - 3/29/2025): Record review of facility 1:1 education on change in condition, falls, physician notification provided to RN A on 03/27/2025 by the ADMIN and DON. Further review of education on change in condition, falls, physician notification to all licensed nursing staff and CNAs provided by the DON and ADON on 3/28/2025. Record review of facility in-services on notification to physician using the Call Tree System dated 3/27/2025 revealed the following: The Physician and Nurse Practitioner Notification Call Tree is posted in all Nurses stations. All direct care staff were educated on the location and use during the in-service conducted by the ADMIN and DON. Observation on 3/28/2025 revealed the Call Tree system posted at both nursing stations. 1. Call 911 if patient needs emergency services. If not, call: 1. NP A, [NP A phone number], 2. MD A [MD A phone number], 3. On-Call Physician Answering Service [phone number], If no answer, please call Management Team - AMDIN, DON, ADON. Record review of the facility audit for monitoring timely provider notifications and change in condition dated 2/28/2025 - 3/28/2025 revealed timely physician notifications. The tool is reviewed weekly. Record review of the facility QAPI meeting dated 3/27/2025 revealed a review of policies/protocols for Change in Condition and Physician Notification, the policies were found to be sufficient. Attendees were the following: ADMIN, MD, and ADON. Record review of the facility in-service on Change in condition and Physician Notification dated 3/27/2025 revealed the MD and PCP in-serviced DON and ADON. Record review of the facility in-service on Physician Notification and Changes in condition dated 3/27/2025 - 3/28/2029 revealed the DON in-serviced all clinical staff. Post test were conducted and completed to ensure understanding and competency. Record review of facility test, given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures. The topics covered were the following: 1. Policy & Procedure on Notification - Physician Notification 2. Policy & Procedure on Quality of Care - Change in a Resident's Condition o A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by the staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. o Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form in MatrixCare. Licenses nurse will follow physician order to call 911(emergency services), if applicable. Interviews were conducted on 3/28/2025 - 3/29/2025 with staff (via phone and in person) on all shifts (6:00 a.m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., 6:00 a.m. - 2:00 p.m (nurses and cnas) included the MD, PCP A, ADMIN, DON, ADON, RN A, RN B, RN C, RN D, RN E, LVN A, LVN B, LVN C, LVN D, CNA A , CNA B, CNA C, Dietary A, and HK A (8:30 a.m. - 5:00 p.m.), to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the Call Tree system - to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the Call Tree system. All were instructed to make a phone call and not to text. Interviews were conducted on 3/28/2025 - 3/29/2025 with staff (via phone and in person) on all shifts (6:00 a.m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., 6:00 a.m. - 2:00 p.m (nurses and cnas) included the MD, PCP A, ADMIN, DON, ADON, RN A, RN B, RN C, RN D, RN E, LVN A, LVN B, LVN C, LVN D, CNA A , CNA B, CNA C, Dietary A, and HK A (8:30 a.m. - 5:00 p.m.), to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the Physician Notification and Changes in condition - to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the how and when to make physician notification and changes in condition. The Administrator was informed the Immediate Jeopardy was removed on 3/29/2025 at 2:52 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of seven residents reviewed for quality of care. The facility failed to follow up with the on-call physician after not receiving a response which delayed Resident #1's transport to the ER after an unwitnessed fall which resulted in a subarachnoid hemorrhage and 6 hour delay in care. Resident #1 was sent to the hospital and admitted to the ICU. An IJ was identified on 3/27/2025. The IJ template was provided to the facility on 3/27/2025 at 2:32 p.m. While the IJ was removed on 3/29/2025, the facility remained out of compliance at a scope of isolated with the severity level of harm that was not immediate jeopardy because all staff had not been trained on 3/29/2025. This failure could place residents at risk for delay in needed treatment and care, resulting in further injury, hospitalization, and/or death. Findings included: Record review of Resident #1's face sheet, dated 3/18/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 diagnoses were not included. Record review of Resident #1's physician progress notes, dated 3/19/2025 revealed the following diagnoses: Alzheimer (memory loss), frequent falls, abnormal gait, seizures, atrial fibrillation (irregular and often very rapid heart rhythm), and insomnia (inability to fall asleep or stay asleep). Record review of Resident #1's care plan, revised on 3/12/2025, revealed the following in part: Category : 11 - Falls. Problem: [Resident #1] has risk for falls related to unsteady gait, disease processes. Goal: [Resident #1] will have no fall related injuries while in the health center through the next 30 days. Seek PT/OT evaluation and treat as ordered and follow recommendations. Keep floor .clean, dry and free of clutter .Reinforce safety precautions with resident . Record review of Resident #1's nursing notes written by RN A, dated 3/15/2025, revealed the following: During my midnight rounding, this writer heard a voice calling out for help, on getting down the hall-way, Patient [Resident #1] was noted on the floor in a semi-Fowler_position on the right side of his bed beside the window holding his head. He was asked what happened and he said I got off the bed and fell help me. When asked whether he [i.e. hit] his head anywhere? Is any part of the body hurting? He was not responding to the questions. He simply stretched out his hand asking to be picked up. No skin break down, swelling nor bruising noted. This writer waited for the CNAs to get mechanical lift. [Resident #1] was assisted back in bed, incontinence care was provided. Vitals: BP 144/88, P 91, T97.6, R 16, O2 sat 96% on R.A. As the writer wants to step out of the room, patient started screaming don't go and was attempting to get out of bed. This writer instructed the aid to sit with the patient, deem [i.e. dim] the light in the room since he is more calm having a company. Checked back after 15 mins for another set of vitals, patient was calm and resting in bed. 10 mins after, the aid told me patient was sleeping. Monitored him throughout the night, no fever, no sign of acute distress noted. Bed in the lowest position, floor mat placed on both sides of the bed, call light within reach. NP notified, she ordered that the patient be sent to the ER for scan. Left voice note for the responsible party as no one was picking the call. Last set of vitals: BP 127/84, P88, T97.8, O2 sat 97% on R.A . Record review of Resident #1's Incident Report dated 3/15/2025 revealed the following (hand written by RN A): Incident Category: Fall without injury. Severity: No injury. Location of incident: Room. Describe the incident: [Resident #1] had an unwitnessed fall, was seen in a semi- Fowler position (individual lies on their back on a bed, with the head of the bed elevated between 30-45 degrees, and the legs of the patient can be either straight or bent at the knees) on the left side of bed beside the window . Resident Description: Per [Resident #1], I got off the bed and fell. Witnessed: Not applicable. Staff Action at Time of Incident: [Resident #1] was assessed for injury and pain, vitals were taken every 15 mins for 1 hour, [Resident #1] was assisted back in bed using mechanical lift. Monitored for any change in condition through out the shift. Neuro/Vital Stats: 1. BP 144/88 P 91 T 97.6 R 16 96% on R.A 2. BP 127/84 P 98 T 97.7 R 16 97% on R.A 3. BP 130/82 P 92 T 97.6 R 18 96% on R.A. 4. BP 122/84 P 98 T 97.6 R 16 97% on R.A. Notified [NP A] by mobile on 3/25/2025 at 1:07 a.m. Record review of NP A's phone text message dated 3/15/2024 at 11:58 p.m. from RN A revealed the following: Text from CNA A to NP A - Good morning, [Resident #1] [room #] was noted on the floor beside his window. He was holding his head (it was not obvious whether he hit his head on the window frame or not). When asked what happened, he was unable to explain (confused) Bp 144/88, P 91, T 97.6, R 16, O2 sat is 96% on R.A. NP A's response text message at 6:22 a.m. to CNA A - Pt needs to go to ER for scan. NP A's response text message at 6:23 a.m. to CNA A - After 10pm I need you to call for urgent changes in condition. I was asleep. Just saw this. Record review of Resident #1's hospital record dated 3/15/2025 revealed the following in part: .History of Present Illness: [Resident #1] .presented on 3/15/2025 via EMS after a fall last night at nursing home. Per report, pt fell while he was trying to get out of bed last night. In ED, pt had CT (medical imaging test) brain which showed small SAH (bleeding in the space below one of the thin layers that cover and protect the brain) in right frontotemporal and left frontal region .Neurologic: Traumatic b/I SAH, on admission, Acute post-concussive enceph (Encephalopathy - disease that affects brain structure or function), on admission .Assessment plan: His CT was positive for small amounts of right subarachnoid hemorrhage in the frontal parietal area. Patient is neurologically stable at this time with only mild confusion. He does not remember the episode. Neurosurgery team was consulted for further evaluation. His neurological exam is nonfocal (no specifics). His labs were normal. At this point I recommend an interval CT scan to confirm stability. Will plan to see him back in neurosurgery clinic for head CT in 1 month. In an interview and observation on 3/18/2025 at 1:06 p.m. (hospital), Resident #1 said he had a fall. He said he did not remember who helped him after the fall. He said he had pain at the time of the fall to his head and legs. Resident #1 was being picked up by medical transport to return to the nursing home. In an interview on 3/19/2024 at 9:38 a.m., CNA A said RN A called her to Resident #1's room. CNA A said she saw Resident #1 on the floor. CNA A said Resident #1 was aware he fell. She said he had a bowel movement that was visible. She said RN A assessed Resident #1 on the floor. CNA A said she left to go and get the mechanical lift. She said she and RN A placed Resident #1 into his bed. She said RN A instructed her to stay with Resident #1. She said Resident #1 fell asleep after approximately 20 minutes and she left the room. She said she continued to round on him every 2 hours and RN A rounded too. She said she was not aware of who and when RN A made notifications. In an interview on 3/18/2024 at 6:43 p.m., RN A said she hear Resident #1 yell out for help. RN A said she went into Resident #1's room and found him on the floor near the window. She said was holding his forehead. She said he was aware he had fell. She said she asked him if he had pain, and he did not respond. She said she did not consider his confusion a change in condition. She said she completed a head-to-toe assessment and took his vitals. She said there were no visible injuries, and his vitals were within normal range. She said she text NP A at 1:07 a.m. that Resident #1 fell. RN A said NP A did not respond. RN A said she did not make a second notification after she did not hear back from NP A. RN A said she was trained to notify the physician by phone. She said she did not make a second notification based on her nursing judgement, that Resident #1 was stable. RNA said after she did not get a response from the NP and Resident #1's vitals and initial neuro checks were within normal range based on her nursing judgement. She said NP A text her back at 6:22 a.m. to send Resident #1 out to the ER for a scan. RN A said she did not think Resident #1 delay in being transported to the ER was at risk of any harm because she felt he was stable. In an interview on 3/19/2025 at 9:45 a.m., NP A said she was notified by text message on 3/15/2025 at 1:07 a.m. Resident #1 had a fall. NP A was notified in the text message that Resident #1 was confused and was holding his head when he was found on the floor. She said she was on call, but asleep at 1:07 a.m. and she woke up and responded to the text message at 6:22 a.m. She said she checked and did not have a missed phone call from RN A. She said based on the details of the notification she wanted the resident to be sent out when she was notified. She said the resident was at risk of a possible head injury since he was holding his head, it was unwitnessed, and he needed to be sent out to the hospital for further evaluation. She said she preferred the resident had not been allowed to fall asleep after there was a possibility he hit his head because that could have been a change in condition. She said Resident #1 should have sent out to the ER immediately to reduce the risk of injury and the delay could have impacted the resident negatively. In an interview on 3/19/2025 at 11:50 a.m., the DON said RN A was trained to make a phone call to notify the physician or NP on call. DON said because RN A's assessment deemed Resident #1 was stable and the resident's vitals were within normal range. She did not think there was a risk to Resident #1 health and the delay to the ER would not have affected Resident #1. In an Interview on 3/19/2025 at 1:15 p.m., the ADMIN said she expected RN A to call the NP (on call) after a fall. She said RN A should have called her also if she did not receive a call back from NP A. She said there are postings of whom to call after an incident. She said the time that lapsed between Resident #1's fall and when he was sent out to the ER was concerning to her. She said staff were trained to call by phone to notify a physician. She said there was no risk because RN A monitored the resident and sent out to the ER after NP A responded several hours later. Record review of facility policy Assessing Falls and Their Causes (revised 10/2010) 1. If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities . 4. Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . 8. If causes of a fall cannot be readily identified and if the fall is accompanied by other signs and symptoms (e.g., confusion or lethargy), the staff and physician will consider a possible underlying acute medical cause. Review of facility policy for Accidents and Incidents-Investigating and Reporting, revised 2/2014, reflected the following in part: All accidents or incident involving residents .etc., occurring on our premises shall be investigated and reported to the Administrator . g. The time the injured person's Attending Physician was notified, as well as the time the physician responded ' his or her instructions; Review of facility policy for Chang in a resident's condition or status (revised 2/2021) reflected the following in part: Our facility promptly notifies the resident, his or her attending physician .of changes in resident's medical/mental condition and /or status . 1. The nurse will notify the resident's attending physician or physician on call . Review of the facility's call procedure Change in a resident's condition and notification, (not dated), reflected the following: Please notify the Administrator IMMEDIATELY on the following .2. Change of Condition/Incidents/Accidents/Falls .etc. - [ADMIN and ADMIN phone numbers]] An IJ was identified on 3/27/2025. The IJ template was provided to the ADMIN on 3/27/2025 at 2:33 p.m. The following Plan of Removal submitted by the facility was accepted on 3/28/2025 at 3:41 p.m.: Allegation: The facility failed notify the on-call physician in a timely manner after Resident #1 had an unwitnessed fall. 03/28/2025 Plan of Removal F580 Facility Name and Vendor ID#: [Facility Name] Impact Statement: On 03/18/2025 a complaint survey was initiated at [Facility Name]. On 03/27/2025, the facility was provided notification that the survey agency had determined that the conditions at the facility constitute an immediate jeopardy to resident health. The facility failed to obtain emergency services for unwitnessed fall for Resident #1 after a fall on 03/15/2025 that resulted in acute subarachnoid hemorrhage (blood on the surface of the brain). Resident #1 arrived at the ER approximately 6 hours after the fall. Immediate Action: Please accept this as our Plan of Removal for the Immediate Jeopardy related to F580 (Physician Notification/Residents Rights) involving failure to immediately notify the physician after a significant change in condition. Resident #1 was readmitted back to the facility on [DATE] from a local area hospital. Residents that can be affected are those who reside in the community. All facility residents were assessed for any Change in Condition. Completion date: 03/27/2025 1:1 education was immediately provided to RN A on 03/27/2025 by the Director of Nursing and Administrator. Education has been extended on 03/28/2025 to all licensed nursing staff and CNAs. Instructor: DON and ADON Direct care staff (PRNs, new hires, from vacation) will not be allowed to render care until in-service is completed. Test questions were given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures. The topics covered were the following: 1. Policy & Procedure on Notification - Physician Notification 2. Policy & Procedure on Quality of Care - Change in a Resident's Condition o A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by the staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. o Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form in MatrixCare. Licenses nurse will follow physician order to call 911(emergency services), if applicable. 3. Updated Physician and Nurse Practitioner Notification Call Tree The updated call tree was completed on 03/27/2025. The appropriate action is to call 911 if the situation is emergent. The Physician and Nurse Practitioner Notification Call Tree is posted in all Nurses stations. All direct care staff were educated on the location and use during the in-service conducted by the Director of Nursing and the Administrator. Completion Date: 03/27/2025 Systematic Approach: Audit tools/checklists were developed to monitor timely provider notification and change-in-condition documentation. Registered and licensed nurses were educated on these audit tools. Completion date: 03/28/2025. A Notification Report audit on Change in Condition for residents in the last 30 days was reviewed and completed. These tools will be reviewed weekly for compliance. Reviewed by: Director of Nursing and Administrator The Administrator notified the Medical Director of the Immediate Jeopardy on 03/27/2025 at 3:11 p.m. An emergency QAPI meeting was held on 03/27/2025, which was inclusive of a review of our policies/protocols for Change in Condition and Physician Notification, the policies were found to be sufficient. Attendees were the following: Administrator, Medical Director, and Assistant Directors of Nursing. The Director of Nursing and the ADON were in-serviced by the Medical Director, PCP A on Change in Condition and Physician Notification on 03/27/2025. Staff in-services, to include all registered nurses, licensed clinical staff, were started on Physician Notification and all clinical staff on Changes in condition; this in-servicing will continue until all clinical staff have been trained. Staff will not be allowed to start on the floor or give care until this training has been completed. All new clinical staff will receive the in-services as part of the onboarding orientation process prior to being assigned and providing care to residents. All licensed clinical staff, will be in-serviced on Physician Notification and all clinical staff will be in-serviced on Changes in Condition. Post tests were conducted and completed to ensure understanding and competency. Completion Date: 03/27/2025 Verified by: -DON All current residents were assessed to determine if there is any change in status and/or condition. The assessments were noted in the individual residents' EMR's. The physician will be made aware of any noted changes from the resident's normal baseline. This will be completed by the registered/licensed nurses and nursing leadership. Completion Date: 03/27/2025 After completion of the residents' audits, no other residents were found to be at imminent risk of having a change in condition and at their normal baseline completed 03/27/2025. Who will be responsible: Director of Nursing and ADONs Who will monitor: Administrator \ Monitoring of the plan of removal included the following (3/28/2025 - 3/29/2025): Record review of facility 1:1 education on change in condition, falls, physician notification provided to RN A on 03/27/2025 by the ADMIN and DON. Further review of education on change in condition, falls, physician notification to all licensed nursing staff and cnas provided by the DON and ADON on 3/28/2025. Record review of facility in-services on notification to physician using the Call Tree System dated 3/27/2025 revealed the following: The Physician and Nurse Practitioner Notification Call Tree is posted in all Nurses stations. All direct care staff were educated on the location and use during the in-service conducted by the ADMIN and DON. Observation on 3/28/2025 revealed the Call Tree system posted at both nursing stations. 1. Call 911 if patient needs emergency services. If not, call: 1. NP A, [NP A phone number], 2. MD A [MD A phone number], 3. On-Call Physician Answering Service [phone number], If no answer, please call Management Team - AMDIN, DON, ADON. Record review of the facility audit for monitoring timely provider notifications and change in condition dated 2/28/2025 - 3/28/2025 revealed timely physician notifications. The tool is reviewed weekly. Record review of the facility QAPI meeting dated 3/27/2025 revealed a review of policies/protocols for Change in Condition and Physician Notification, the policies were found to be sufficient. Attendees were the following: ADMIN, MD, and ADON. Record review of the facility in-service on Change in condition and Physician Notification dated 3/27/2025 revealed the MD and PCP in-serviced DON and ADON. Record review of the facility in-service on Physician Notification and Changes in condition dated 3/27/2025 - 3/28/2029 revealed the DON in-serviced all clinical staff. Post test were conducted and completed to ensure understanding and competency. Record review of facility test, given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures. The topics covered were the following: 1. Policy & Procedure on Notification - Physician Notification 2. Policy & Procedure on Quality of Care - Change in a Resident's Condition o A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by the staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. o Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form in MatrixCare. Licenses nurse will follow physician order to call 911(emergency services), if applicable. Interviews were conducted on 3/28/2025 - 3/29/2025 with staff (via phone and in person) on all shifts (6:00 a.m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., 6:00 a.m. - 2:00 p.m (nurses and cnas) included the MD, PCP A, ADMIN, DON, ADON, RN A, RN B, RN C, RN D, RN E, LVN A, LVN B, LVN C, LVN D, CNA A , CNA B, CNA C, Dietary A, and HK A (8:30 a.m. - 5:00 p.m.), to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the Call Tree system - to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the Call Tree system. All were instructed to make a phone call and not to text. Interviews were conducted on 3/28/2025 - 3/29/2025 with staff (via phone and in person) on all shifts (6:00 a.m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., 6:00 a.m. - 2:00 p.m (nurses and cnas) included the MD, PCP A, ADMIN, DON, ADON, RN A, RN B, RN C, RN D, RN E, LVN A, LVN B, LVN C, LVN D, CNA A , CNA B, CNA C, Dietary A, and HK A (8:30 a.m. - 5:00 p.m.), to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the Physician Notification and Changes in condition - to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the how and when to make physician notification and changes in condition.] The Administrator was informed the Immediate Jeopardy was removed on 3/29/2025 at 2:52 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.