Health inspection·May 8, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident's emergency contact was notified of a fall and a change in condition. This affected one (Resident #3) of three reviewed for notification of changes. The facility census was 91. Findings include: Review of Resident #3's closed medical record revealed an admission date of 01/24/24. Diagnoses included muscle weakness, vascular dementia, heart failure, and pleural effusion. Resident #3 was transferred to a local hospital on [DATE] and did not return to the facility. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10. Review of the progress notes dated 04/06/24 at 3:46 P.M. revealed Resident #3 was found by an State Tested Nursing Assistant (STNA) sitting upright on the floor next to his bed with his wheelchair next to him. The wheelchair was locked and Resident #3 was wearing gripper socks. Resident #3 stated he was standing to transfer from his wheelchair to his bed and his feet slipped out from under him causing him to slide to the floor landing on his bottom. Resident #3 denied any head injury. Resident #3's physician and son were notified. Resident #3's son was not listed as an emergency contact. Review of the neurological checks conducted post-fall revealed Resident #3's level of consciousness (LOC) had declined from one (alert wakefulness: responds quickly and appropriately) on 04/07/24 at 3:15 A.M. to a two (drowsy/lethargic: responds to stimuli appropriately, but with delay and slowness) on 04/07/24 at 7:15 A.M. Resident #3's LOC was documented as two on 04/07/24 at 11:15 A.M. and 3:15 P.M. The progress notes dated 04/07/24 at 1:28 P.M. revealed Resident #3 was increasing lethargic and drowsy. Resident #3's blood pressure was trending low. There was no documentation of Resident #3's emergency contact being notified of the decline in LOC until 04/07/24 at 7:50 P.M. when Resident #3's emergency contact came to the facility and had concerns about Resident #3's hallucinations and twitching. Resident #3 was sent the the emergency room (ER) for evaluation. Interview on 05/08/24 at 11:20 A.M. with the Director of Nursing (DON) and Register Nurse (RN) #75 revealed when Resident #3 fell on [DATE], Licensed Practical Nurse (LPN) #50 was the nurse assigned Page 1 of 2 365422 365422 05/08/2024 Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309

F 0580 Level of Harm - Minimal harm or potential for actual harm to his care. A family member came to visit Resident #3 on 04/06/24 after his fall and LPN #50 at first believed this family member was the Resident #3's emergency contact. When discussing Resident #3's fall with this family member, she discovered he was not the emergency contact. LPN #50 thought she heard this family member talking to the listed emergency contact on the telephone. LPN #50 did not call Resident #3's listed emergency contact about the fall on 04/06/24. Residents Affected - Few Telephone interview with LPN #50 on 05/08/24 at 1:36 P.M. revealed she was the nurse caring for Resident #3 when he fell on [DATE]. A family member came to visit Resident #3 right after the fall on 04/06/24. LPN #50 talked with this family member about fall interventions and thought the family member had spoken with Resident #3's emergency contact about Resident #3's fall. LPN #50 confirmed the family member she had spoken with on 04/06/24 was not Resident #3's listed emergency contact. LPN #50 stated that Resident #3 was lethargic the next day (04/07/24) and had called Resident #3's physician. LPN #50 did not call Resident #3's emergency contact about Resident #3's decline in LOC on 04/07/24. Review of the facility's policy titled Notification of Changes Policy, revised 11/02/16, revealed the facility will inform the resident, the attending physician and the resident's representative or interested family member of changes which affect the resident. The facility must inform the resident immediately, the attending physician and the resident's representative or interested family member when there is: • An accident involving the resident, which may or may not result in injury. • A significant change in the resident's physical, mental or psychosocial status. • A need to alter treatment significantly. • A decision to transfer or discharge the resident from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00153323. 365422 Page 2 of 2