**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 1 (R19) of 12 residents out of a total sample of 14 residents received assessment and appropriate and timely medical care with a change in medical condition. R19 had an unwitnessed fall on 10/21/23 at 6:15 PM. R19 experienced change of condition and the facility failed to properly assess range of motion (ROM)/change in ambulation ability on 10/21/23. The facility failed to identify change in resident when resident experienced the inability to move right leg and increased weakness on 10/21/23 and the morning of 10/22/23. R19 went to emergency room on [DATE] at 11:00 AM and was diagnosed with a right hip fracture. Evidenced by The facility policy titled, Notification of Change in Condition, with a revision date of 12/31/22, states, in part; .PURPOSE to ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when: 1. An accident involving the resident which result in an injury and has the potential for requiring physician intervention. 2. A significant change in the resident's physical, mental or psychosocial status. 3. A need to alter treatment significantly. Sample reasons to notify the physician immediately but not limited to: .2. Need to alter treatment significantly .5. A fall with significant injury .PROCEDURES 1. Resident assessments for change in condition, suspected injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed in a timely manner .4. Documentation of notification or notification attempts should be recorded in the resident electronic health record . The facility policy titled, Falls Management Program Guidelines, with a revision date of 3/16/22, states, in part; .PROCEDURE .2. Should the resident experience a fall the attending nurse shall complete the Fall Event This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions 5. The resident care plan should be updated to reflect any new or change in interventions. 6. Nursing staff will monitor, and document continued resident response and effectiveness of interventions for 72 hours. 7. Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report . R19 was admitted to the facility on [DATE] with diagnoses including: unspecified dementia without behavioral disturbance, unspecified osteoarthritis, muscle weakness, repeated falls, other symbolic dysfunctions, weakness, mixed hyperlipidemia, and sick sinus syndrome. R19's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/1/23, indicates R19 has a Brief Interview for Mental Status (BIMS) score of 4 out of 15 indicating R19 is severely cognitively impaired. R19 has an activated power of attorney. R19's Comprehensive Care Plan, states, in part; Problem Start Date: 10/20/23 Resident demonstrates signs and symptoms of OCD (obsessive compulsive disorder). Goal: Resident's OCD symptoms will be lessened with assist of anti-depressant. Approach: Encourage resident and representative to participate in Resident First Meetings and plan of care. Encourage resident to voice concerns, feelings, and problems as they occur rather than internalizing. Give meds as ordered and monitor for side effects and monitor behaviors. Observe mood, affect, and behaviors with all hands-on care and treatment Provide 1:1 supportive contact as needed. Res may need redirection due to non-compliance and resistance with ADLs/interventions for falls. Problem Start Date: 7/24/23 Demonstrates non-compliance with plan of care as evidenced by choosing to get up and move around his room on his own without assistance. Has reminders in his room that he should ask for assistance with standing and moving around his room. States he has gotten up on his own for many years and he does not feel that there is a need to ask for help. Has had falls in the past. Goal: Preferences will be honored to the extent that non-compliance with his plan of care will not result in injury to himself. Approach: Educate regarding his plan of care and risk and benefits of compliance . Problem Start Date: 4/6/23 ADL's Resident requires staff assistance to complete ADL tasks completely and safely. Goal: Resident will have ADL needs met safely by staff. Approach: .Allow Resident sufficient time to complete all or parts of task. Do not rush resident .Observe for deterioration in ADL abilities and report if occurs Problem Start Date: 4/3/23 Falls has a potential for falls related to cognitive issues. Goal: Will not sustain serious injury through the review date. Approach: 10/3/23 Provide resident with safety devices/appliance: wedge cushion in w/c when up. 9/11/23 Anti-lock brakes to prevent w/c for moving when res is non-compliant with transferring self. 8/6/23 Have staff offer frequent toileting when res is awake. 7/19/23 Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c. Grippy socks on at night. 5/16/23 Leave night light on in room. Notes remain in room reminding resident to ring for assist. 4/3/23 Be sure my call light is within reach and encourage me to use it for assistance as needed. 4/3/23 PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed) . Problem Start Date: 10/27/23 Pain At risk for pain R/T (related to): arthritis and fracture. Goal: Resident's pain will be at a tolerable level with interventions. Approach: 10/27/23 Administer medications as ordered and notify MD for any side effects observed or lack of effectiveness. 10/27/23 Attempt non-pharmacological interventions. 10/27/23 Notify MD of increased pain. 10/27/23 Observe for and record verbal and non-verbal signs of pain. 10/27/23 Reposition as needed . It is important to note R19's care plan for pain is started when readmitted after fall with fracture. R19's care plan does not include what an acceptable pain level is for R19, nor does it include how R19 expresses pain if he is not able to verbally communicate that he is in pain. R19's Medication Administration Record/Treatment Administration Record (MAR/TAR) October 2023, states, in part; Order Set Target Behavior- OCD tendencies, restlessness, refusal of cares. At the end of each shift mark frequency- how often behavior occurred & intensity- how resident responded to redirection. Intensity code: 0=did not occur; 1=easily altered; 2=difficult to redirect. Frequency Three times a day. Special Instructions If you mark anything but zero, please make a progress note. R19's documentation shows from October 1st-18th that the behavior did not occur or that R19 was easily able to redirect. On 10/18 2 difficult to redirect. On 10/21 (day of fall) it shows 0 documented on AM shift (7a-3p), 0 documented on PM shift (3p-11p) and 1- easily altered. On 10/22 the documentation is blank. R19's MAR/TAR October 2023, states, in part; Order Acetaminophen (OTC - over the counter) tablet; 325mg; PO every six hours-PRN .take 2 tablets orally every six hours as needed for pain or fever .10/21 (day of fall) Time 11:27PM PRN Reason: Pain. Temperature Before 97.5F. Pain Before: 0 numeric (0-10). PRN result follow up: E. PRN result 1:16AM PRN Result-Follow up: Effective. It is important to note R19's Neurological Checklist from 10/21/23-10/22/23 indicates 10/10 pain at 8:15PM-10:15PM. Surveyor reviewed R19's October 2023 Progress Notes. R19's resistive to cares, will decline assistance from staff. R19's documentation shows R19 will state he can do tasks on own, does not need assistance. R19's documentation shows R19 will stand up on own, attempt to self-transfer, impulsive, and noted confusion. R19 had one documented physical aggression prior to fall with fracture on 10/21/23. On 10/14/23 .CNA reported cursing, grabbing, hitting, kicking, screaming, and threatening comments during cares. In bed sleeping soundly at this time. No other documented physical aggression until 10/21/23. On 10/20/23 7:40am resident slept well throughout the night with no attempts to get out of bed on own. Checked on frequently throughout the night. 10/20/23 4:26pm citalopram given as ordered. Resident calm and cooperative with cares today. Sitting in room with wife this pm holding hands. On 10/21/23 2:08am Resident checked frequently during the night no attempt to get out of bed. Slept well during the night. (It is important to note Nurses Progress note does not have any documentation of R19's fall on 10/21/23.) On 10/22/23 1:16pm (RN N documented), Resident lying in bed on his back without changing position early in shift. Resident uncooperative at 8am with assessment of limbs. Refused to get out of bed. Refused to eat breakfast or take medications. Refused to get out of bed. Refused to eat breakfast or take medications. Refused to allow staff to clean him or assist with dressing. Multiple attempts to accomplish the above-mentioned tasks. Staff checked on resident multiple times. Resident finally agreed that he needed assistance and allowed limb assessment at 11am. Stated that R knee is painful. Resident would not straighten RLE (right lower extremity). R (right) knee larger than L (left). VSS wnl (vital signs within normal limits) at 8am. Blood pressure 164/62, HR 74, R 20, T 97.1, O2 94% at 11am. L lip drooping, resident oriented to self only, red face. Spoke with POA (power or attorney) .On call MD. Both stated to send resident to the hospital. Called ambulance to transport. Ambulance arrived within 30 minutes of call. ADON (assistant director of nursing) notified of transport to hospital. Resident cleaned up by staff. Paperwork sent including POA document, face sheet, orders. Received call from RN at ER (emergency room) who asked questions regarding resident baseline and POA phone number. RN stating that resident was running temp of 100.3 at time of admission to ER. ER staff will contact POA (power of attorney), and facility as needed .10/22/23 5:56pm Message received from ER. Resident admitted .Message did not state diagnosis. 10/23/23 7:21pm Late entry: (RN M late entry from noc (night) 10/21 .) Resident sleeping quietly during Neuro Checks during the night. Resident was asked if he was in any pain. Resident responded with (what do you want?) Resident check every hour during the night. LPN (licensed practical nurse) and CNA (certified nursing assistant) went to get Pt (patient) up for breakfast and Pt was very combative grabbing and pulling at staff. Refusing care. Yelling get out of here. LPN asked resident if he was in any pain. LPN noticed when moving Pt (patient) he would yell (Get away leave me alone). Holding on to his covers not allowing to be changed. Pushing and grabbing CNA arms. Report was given during change of shift to RN. Vitals were taken and each neuro check during the night. Resident uncooperative with care . R19's Fall Event from 10/21/23, states, in part; event date: 10/21/23 6:16pm, completed date 10/23/23 7:55pm. Description: Resident fell out of his wheelchair while in his room- unwitnessed event at 18:15 (6:15 PM). Resident scraped his right elbow open wound noted. Site cleansed with alcohol, ABD (bandage) and tape applied. No injury to his head reported. A&O at time of event. Resident denied pain at that time. Resident later complained of inability to move his right leg/hip given Tylenol and ice packs applied to right hip. VSS .Location of Fall Resident Room. What was resident doing just prior to fall? Transferring self Was Fall witnessed? No-initiate neuro check order set. Did Resident hit head? No .Other contributing factors Resident refused to comply with safety measures such as call light use, alarms, appliances, etc.new interventions- other, describe- frequent rounding q (every) 15 mins (minutes). R19 Neurological Checklist from 10/21/23-10/22/23 states, in part; .6:15PM R Leg/hip weak until 10:15PM .Pain 10/10 at 8:15PM-10:15PM .vital signs within normal range. 11:15PM-4:15AM states resident is asleep and that neurological checks were completed, and vitals completed. 8:15AM documented that resident refused ROM/assessment of legs . The facility internal investigation timeline states, in part; .On 10/21/23, at 1815 resident had an unwitnessed fall from his w/c. Stated that he didn't hit his head. Resident A&O (alert and oriented). Does have episodes of confusion and forgetfulness. C/O (complained of) pain to right elbow. Nurse inspected right elbow and noted an abrasion present. Temp 97.5 spo2 97% on RA (room air). Scraped his right elbow Right elbow minor abrasion noted. Wound cleansed and ABD pad applied. Resident denied c/o pain to any other body part. On call physician informed. Per CNA statement, resident was last seen after supper, when she assisted him back to his room, which would have been approximately 1700-1715 (5:00 - 5:15 PM). Per Nurse's statement, resident did not c/o any pain initially after the fall. He was assisted up with 2 assists back to his w/c (wheelchair). There was no evidence of right leg shortening, internal or external rotation. The nurse and CNA checked on resident frequently after the fall. No c/o's were expressed. No verbal or nonverbal expressions of pain were reported by resident. At approximately 2130 (9:30 PM), resident c/o pain in his right hip. The nurse assessed him and applied an ice pack to right hip and administered Tylenol as ordered. PM nurse reported off to NOC nurse for further monitoring. NOC nurse and CNA checked on resident several times during the night. Resident was sleeping soundly. No c/o pain was expressed. Between 0530 AM and 0600 AM, the nurse and CNA were in resident's room to get him checked and changed and ready for breakfast. The resident did not want to be touched, told staff to leave him alone. He also c/o right hip pain. Staff made sure resident was safe and reported off to oncoming shift. NOC nurse informed Day shift nurse of resident's c/o right hip pain and asked that she call the MD and update him/her. Day shift nurse reported that resident was checked on frequently and he repeatedly refused to allow staff to change him, reposition him or get him dressed. At 11am, resident agreed to allow the nurse to complete an assessment on him. Resident stated that his right knee was painful. The nurse stated resident's right knee was larger than his left. POA and on call MD were updated on resident's condition and was advised by both to send resident to the hospital. Resident was transported by ambulance to hospital. History: Resident has a history of being very independent and non-compliant, refusing cares, staff assistance for most things and following/allowing fall interventions to be initiated and used. He believes he can do more independent tasks than what he really is capable of doing. Resident has a hx of falls . Surveyor reviewed witness statement forms from internal investigation. Witness statement forms state, in part. RN L (Registered Nurse) .I last saw resident when he was in his w/c (wheel chair) eating dinner. After he was discovered, he did not c/o any pain in legs or hips. Only c/o pain in right elbow/forearm where he sustained an abrasion. 2 staff assisted him off the floor to his w/c. There was no evidence that he had any problems with his right leg/hip. No c/o pain. No shortening or rotation. I informed the oncoming nurse of resident's fall and c/o of inability to move his right leg. RN M .I worked the night shift on 10/21. Resident slept the entire night. He did not have any c/o's. He doesn't always tell us when he is in pain. We checked on him often during the night and he was sleeping each time. At 0530 (5:30 AM), we went to check and change him and get him up and dressed for breakfast. We made him possibly send him out. {sic} RN N .written statement not provided to Surveyor. CNA H (Certified Nursing Assistant) .I am not sure of what resident was doing prior to the fall. I was at the other end of the building when the fall happened. I last saw resident after supper when I helped him to his room, about 1700-1715 (5:00 PM - 5:15 PM), because he didn't know which way his room was. He was sitting up in his w/c. I didn't see him after the fall. I only knew of his fall after it had happened. I didn't have any interaction with him after the fall. CNA P I looked frequently into resident's room when walking. He was in his room in his w/c. he was messing around with stuff on his dresser before he was found on the floor. Around 6pm, I'm not sure of the time, the nurse came and asked me if I could come help transfer resident off the floor. He stood well and we assisted him back into his w/c. I assisted him with cares. The nurse put ice on his hip later. CNA Q .I worked the night shift and took care of resident. He slept most of the night. I checked on him during each round. He didn't have any c/o pain during the night. He didn't want me to touch him for turning or check and change. At approximately 6am, the nurse and I were helping to position him in bed. On 11/28/23 at 11:07AM, Surveyor observed R19. R19 indicated he did not think that he had any falls while at the facility, but that he can't remember. R19 indicated he felt comfortable and voiced no concerns. On 11/29/23 at 4:08PM, RN O (Corporate Registered Nurse) indicated she was notified of R19's fall with fracture and the need to complete an investigation. RN O indicated she conducted the investigation and collected statements from the staff who worked on 10/21/23 and 10/22/23. RN O indicated she asked the staff who worked questions about R19's pain and if he experienced any pain. RN O indicated initially R19 did complain of some knee and hip pain. RN O indicated it was reported to her that R19 slept all night and didn't complain of any pain. RN O indicated it was reported to her that R19 woke up around 5:30-6:00 AM and that he didn't want to be bothered, and that was not unusual for him. RN O indicated the NOC staff got him cleaned up and got him ready for breakfast. RN O indicated it is not unusual for R19 to refuse cares. Surveyor asked RN O about the internal investigation timeline that RN O provided Surveyor. Surveyor asked specifically about the following statement from NOC RN, Between 0530 and 0600, the nurse and CNA were in resident's room to get him checked and changed and ready for breakfast. Resident did not want to be touched, told staff to leave him alone. He also c/o right hip pain. Staff made sure Resident was safe and reported off to oncoming shift. NOC nurse informed Day shift nurse of resident's c/o right hip pain and asked that she call the MD and update him/her. Surveyor asked if at that time was MD contacted? RN O indicated I don't know. Surveyor asked RN O to please provide any other additional documentation or information that the facility may have regarding R19's fall investigation. On 11/29/23 at 4:30 PM, RN N indicated she was the AM nurse on 10/22/23. RN N indicated the NOC nurse reported to her that R19 had a fall. RN N indicated that R19 will refuse staff assistance and that is normal. RN N indicated she completed vitals but tried not to bug him and let him rest. RN N indicated pain monitoring is completed on the resident's MAR/TAR and in the progress notes. On 11/29/23 at 5:21 PM, RN M indicated she was the NOC RN on 10/21/23. RN M indicated that R19 slept all night and that R19 was in bed all night. RN M indicated that she completed vitals, and they were within normal range. RN M indicated she feels that he doesn't want to cause a ruckus and that he's a man! Surveyor asked RN M about the documented witness statement form she had completed indicating R19 was in pain at 5:30 AM. RN M indicated I might have written that, but that's not exactly what I meant. RN M indicated it was normal for R19 to decline cares and that you need to reapproach. RN M indicated she passed all of this on to the oncoming AM nurse. RN M indicated she did not notify MD at 5:30-6:00 AM when R19 refused to get out of bed. On 11/30/23 at 10:10 AM, Surveyor asked RN O if the facility completed any education with the nurses after the 10/21/23 incident. RN O indicated, We did. Surveyor asked RN O to provide any education the facility completed with nurses regarding areas of concerns they identified from the 10/21/23 incident. On 11/30/23 at 10:20 AM, DON B (Director of Nursing) indicated they had a DON B indicated she was making a copy of what was reviewed from the 10/30/23 meeting and putting it at the nurse station today as well. On 11/30/23 at 10:30 AM, LPN J (Licensed Practical Nurse) indicated she knows R19 very well. LPN J indicated R19 can be a very stubborn man and has past trauma from childhood. LPN J indicated if R19 feels like he is being hurried or rushed he will refuse cares and assistance. LPN J indicated if R19 feels something should be done a certain way, there is no changing his mind. LPN J indicated R19 does take a little bit more time assisting him with cares. LPN J indicated for example, prior to the 10/21/23 fall when it was R19's shower day, they will talk about it earlier in the day and write a note for him because if R19 starts to change his clothes in the evening, he will refuse the shower. LPN J indicated if he has that reminder, he most likely will wait and take his shower. Surveyor asked LPN J how does staff know if R19 is in pain? LPN J indicated if he is calling out, moaning, restless, and he will tell you if he is in pain, but you have to ask. LPN J indicated she did not think R19 would just come out and tell someone he is in pain. LPN J indicated R19 can be combative so if he was to be more combative than usual, I would question that. LPN J indicated if R19 would refuse bingo that would be an indicator. LPN J indicated she had more of a 1:1 informal conversation with DON B after the 10/21/23 incident. LPN J indicated she heard the staff really fought R19 while he was in bed after the fall because they wanted to complete an assessment on him. LPN J indicated she would have sent him out, but she understands the nurses were following procedure and going through the proper channels. LPN J indicated prior to the 10/21/23 fall R19 would self-transfer and LPN J indicated R19 did not experience inability to move right leg. LPN J indicated after an unwitnessed fall vitals should be taken, check ROM, neuro checks, see if the resident can stand and transfer, and get them comfortable/safe. LPN J indicated notifications then need to be made to resident's doctor and POA if necessary. At 11:04 AM, LPN J indicated to Surveyor there was a nurse meeting on 10/30/23, and at that time they went over change of condition and what the process is. LPN J indicated I don't know if it was necessarily for R19's incident. LPN J indicated that usually any time they have a nurse meeting/education there is a staff sign in sheet. On 11/30/23 at 11:29AM, RN M indicated the morning of 10/22/23 R19 was wide awake in bed and was really fighting us! RN M stated, He did not want us touching him at all. Did not! I made sure when RN N came in that morning to report that something wasn't right and that she should see him now before I leave. RN N said she had to pass medications. Surveyor asked RN M if she received education regarding RN M stated the meeting was some kind of discussion about something. RN M indicated it would have been good to go over all of these things that we should do because anything could have happened while he was in that bed. On 11/30/23 at 12:30 PM, DON B indicated she did not have a staff sign off sheet because they had so much to cover at the meeting. On 11/30/23 at 1:57 PM, Surveyor asked DON B what opportunities for improvement did the facility identify after the investigation for the 10/21/23 incident? DON B indicated the communication between shifts and nurses, the need to reassess and notify again after an incident if there is a change with resident, and the fall policy in general. DON B indicated if R19 refuses assistance then the staff need to reapproach him. Surveyor shared with DON B there is a concern regarding the incident. Surveyor indicated the concern is with assessment and timely/appropriate medical care. Surveyor indicated through reviewing facility investigation and nurse interviews it appears there is a concern with communication between nurses as well. On 11/30/23 at 2:10 PM, Surveyor shared with NHA A (Nursing Home Administrator) there is a concern with the 10/21/23 incident and the investigation. Surveyor indicated there is a concern with the lack of assessment, appropriate/timely medical care, and communication break down between shifts. Surveyor discussed education that was completed on 10/30/23 at the nurse meeting. Surveyor indicated there was no staff signature sheet, RN L did not attend/DON indicated she called RN L but no documentation showing this, and through interview staff are not remembering topics that were discussed pertinent to R19's incident. NHA A indicated DON B typically does have a staff signature sheet verifying education was received, NHA A indicated he is not sure why this was not done on the 10/30/23 nurse meeting. On 11/30/23 at 2:40PM, MD R (Medical Director) and RN O indicated they reviewed R19's documentation neurological checklist from 10/21/23-10/22/23. MD R indicated from a clinical standpoint they do not feel the incident rises to a harm level. MD R indicated vital signs were within R19's baseline. RN O indicated when pain was documented, a PRN was given. Surveyor asked MD R and RN O if weakness/inability to move right leg was a change for R19. RN O indicated RN O was not sure and that R19 has a diagnosis of arthritis. Surveyor asked MD R if she had reviewed the nursing witness statement forms and the timeline from the investigation. MD R indicated she had not. Surveyor discussed documentation showing missed opportunities of when the RN should have notified primary doctor and failed to provide timely/appropriate medical treatment. RN O indicated R19 will refuse cares and that is not new. Surveyor questioned the intensity level of physical aggression, and RN O indicated she does not know the resident. Surveyor asked RN O if facility had any other documentation to share with Surveyor. RN O stated, Just what came out of our mouths right now . On 11/30/23 at 3:47 PM, RN L indicated she was the nurse that worked on 10/21/23 when R19 had unwitnessed fall which resulted in fracture. RN L indicated RN L heard a sound and ran to R19's bedroom. RN L indicated R19 reported he didn't hit his head and she noted that his elbow was scratched. RN L indicated R19 was denying that he was in pain after the fall. RN L indicated at the time of the fall she asked him questions about his pain and general assessment questions. RN L indicated, I didn't complete ROM or attempt to move legs because I didn't want to make the situation worse. RN L indicated she notified the on-call MD and talked with RN N and ADON/IP C (Assistant Director of Nursing/Infection Preventionist) after fall. RN L indicated she reported to the NOC RN about the fall, notification that was made, and the treatment she completed to R19's elbow. RN L indicated she reported that NOC RN needs to keep an eye on him. RN L indicated R19 didn't want to go to the hospital and that they need to continue to monitor. RN L stated, Like I said, I tried to document, I'm new to that facility .I did document he refused medical attention. RN L indicated she remembers a conversation she had not with DON B but with ADON/IP C after the incident. RN L stated, I don't remember what we discussed or what was covered. I suggested we need to do more frequent rounding/monitoring . It is important to note it is not documented in Progress Notes, Fall Report, and Witness Statement Report that R19 refused to go to the hospital on [DATE]. The facility failed to re-assess R19 once he complained of pain and inability to move right leg on 10/21/23. The facility failed to ensure timely and appropriate medical attention was provided when R19 expressed a change on the morning of 10/22/23.