Health inspection·February 14, 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 record review, staff interview, review of the grievance log, review of a fall investigation, and facility policy review, the facility failed to timely notify one resident's (Resident #101) representative of a fall resulting in hospitalization. This affected one (Resident #101) of three residents reviewed for notification of changes. The facility census was 95. Findings Include: Review of the closed medical record for former Resident #101 revealed an initial admission date on 01/15/14, a readmission date on 04/16/16, and a discharge date on 01/03/24 due to passing away. Medical diagnoses included dementia with behavioral disturbance, traumatic subdural hemorrhage without loss of consciousness, weakness, unsteadiness on feet, lack of coordination, cognitive communication deficit, anxiety disorder, post-traumatic stress disorder (PTSD), major depressive disorder with psychotic symptoms, and peripheral vascular disease. Review of Resident #101's profile revealed the resident's daughter was the resident's responsible party and was listed as Emergency Contact #1. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #101 was rarely or never understood. Resident #101 had severely impaired cognition, displayed inattention and disorganized thinking. Resident #101 rejected care one to three days out of the review period. Resident #101 required stand by assistance with bed mobility and partial to moderate assistance from staff to complete transfers and ambulation. Resident #101 had one fall since admission or prior assessment with a major injury. Review of the progress notes for Resident #101 revealed on 12/20/23 at 4:49 P.M., Resident #101 was observed sleeping on a bed in another resident's room. Moments later a nurse walked by and witnessed Resident #101 lying on the floor with his head covered in blood. One nurse held pressure to the resident's head while another nurse prepared paperwork and called emergency medical services (911). On 12/20/23 at 9:00 P.M. (approximately four hours later), Registered Nurse (RN) #222 spoke with Resident #101's daughter regarding the resident's status. On 12/21/23 at 1:37 A.M., Resident #101 returned to the facility at 10:20 P.M. from the hospital. Bruising was noted to the resident's orbital (eye) area up to the right side of his forehead/temple area. There was an open area noted to the corner of the eye area. On 12/21/23 at 6:12 A.M., Licensed Practical Nurse (LPN) #220 noted per the report from the hospital, Resident #101 sustained a subdural hematoma. On 01/03/24 at 7:42 P.M., Resident #101 passed away in the facility at approximately 6:40 P.M. Page 1 of 2 365425 365425 02/14/2024 Embassy of Newark 75 McMillen Drive Newark, OH 43055

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Resident/Family Grievance Log dated December 2023 revealed Resident #101's daughter filed a grievance on 12/21/23 due to not being notified by the facility of the resident's fall or transfer to the hospital. Review of the fall investigation dated 12/20/23 timed 10:40 P.M. revealed the Certified Nurse Practitioner (CNP) was notified on 12/20/23 at 4:40 P.M. and Resident #101's daughter was notified on 12/20/23 at 9:00 P.M. Interview on 02/14/24 at 4:35 P.M. with LPN #250 confirmed Resident #101's fall occurred between 3:00 P.M. and 4:00 P.M. on 12/20/23 and the time indicated on the fall investigation report only indicated when the report was started by RN #215. LPN #250 confirmed Resident #101's daughter was not notified of the resident's fall or transfer to the hospital until 9:00 P.M. (approximately five hours later). LPN #250 confirmed the resident's representative should have been notified immediately of the resident's fall and transfer to the hospital. Review of the facility policy, Assessing Falls and Their Causes, revised 03/2018, revealed the policy stated, notify the resident's attending physician and family in an appropriate time frame when a fall results in a significant injury or condition change. Notify the following individuals when a resident falls: the resident's family, the attending physician, the Director of Nursing Services, and the nursing supervisor on duty. This deficiency represents non-compliance investigated under Complaint Number OH00149698. 365425 Page 2 of 2