MEMPHIS, TN- GRACELAND REHABILITATION AND NURSING CARE CENTER

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37530

Based on policy review, job descriptions, medical record review, observation, and interview, the facility failed to provide supervision and monitoring for 1 of 5 (Resident #4) sampled residents reviewed for unwitnessed falls, failed to ensure the resident’s right to be free from neglect when the facility failed to provide necessary goods and services and failed to treat residents in a manner that promoted a sense of self-worth, dignity and individuality for 11 of 11 sampled residents (Resident #7, #20, #28, #30, #37, #42, #44, #45, #46, #47 and #48) reviewed for daily hair care, and failed to ensure residents’ vital signs were monitored [DATE], February 2024, [DATE] and [DATE], for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, and #24 ) sampled residents reviewed on the Crown Unit, a unit with residents that are dependent on ventilators and high acuity care requirements.

Resident #4 experienced unwitnessed falls on [DATE], [DATE], [DATE], and on [DATE]. The facility failed to monitor Resident #4’s condition post unwitnessed fall per facility policy which resulted in Immediate Jeopardy (IJ) when Resident #4 did not receive neurological (neuro) checks (examination to determine whether the nervous system is impaired affecting the brain), frequent vital signs (measurement of the body’s most basic functions) monitoring and supervision after an unwitnessed fall on [DATE] at 2:00 AM. Resident #4 had a decline in condition and was not transferred to the hospital until [DATE] at 2:22 PM, approximately 36 hours after the unwitnessed fall on [DATE]. Resident #4 was admitted to the hospital on [DATE] with Acute on Chronic Subdural hematomas (subdural hematoma is a blood clot collection of blood between the brain and the brain’s outer covering, usually with an injury that jolts or shakes the brain) with a right to left midline shift (indicates a significant increase in pressure in the brain pushing the brain to the right or left) and required an emergency craniotomy (Surgery on the brain to treat the bleeding in the brain).

The facility’s failure to monitor resident’s Activities of Daily Living (ADL) care including daily hair care resulted in HARM for 11 of 11 residents (a situation in which the provider’s noncompliance resulted in neglect that compromised the residents’ ability to maintain and/or reach his/her highest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services), cited at a scope/severity of H which is substandard quality of care.

Review of the Emergency Medical Services (EMS) report dated [DATE] revealed EMS received an
emergency call on [DATE] at 1:40 PM and arrived at the nursing home at 2:00 PM. The EMS report revealed, .en-route to [Named Facility] .for emergency complaint of altered mental status post-fall .on arrival, pt [Resident #4] was .minimally responsive .Nurse stated pt fell x [times] 2 days ago . ‘ neuro checks’ were started this morning approx [at approximately] 0200 [2:00 AM] .at 2:30 [AM] and had degraded .Pt has hx [history] of trauama [trauma] subdural hematoma .Pt would open eyes to loud verbal stimulus at times pt would not respond unless painful stimulus was applied .pupils were unequal at 4mm [millimeters] on left and 5 mm on right .reactive to lights . EMS left the facility at 2:22 PM, transporting Resident #4 to the hospital Emergency Department (ED).

Review of the Hospital ED History & Physical for Resident #4 dated [DATE] at 4:41 PM, revealed .Last known well: Date/time [DATE] 02:30:00 [2:30 AM] . According to the EMS NH [Nursing Home] staff noticed that the patient [Resident #4] is experiencing altered mental status around 2:30 AM [approximately 12 hours prior to arriving to the ED] when they started neuro checks on her and noticed declining mental status .

Review of the Hospital ED Physician Consultation for Resident #4 dated [DATE] at 4:58 PM revealed, .Acute on chronic right subdural hematoma as well as a left acute on chronic subdural hematoma XXX[AGE] year-old female with a past medical history of hypertension, diabetes, thyroid disease and previous subdural hematoma, status post craniotomy in 2019 .She presents today after a fall at her nursing home .The patient has had a progressive decline in her mental status which prompted a presentation to the emergency department for further evaluation. CT [Computerized Tomography] scan demonstrates a large right subdural hematoma with mass effect [increasing pressure within the skull and potentially causing midline shift or deadly brain herniation] and midline shift for which Neurosurgery has been consulted .We will take the
patient emergently to the operating room for a right craniotomy for subdural hematoma evacuation .

Review of the Hospital Records for Resident #4 dated [DATE], revealed .As per the patient’s daughter patient was at her baseline alert oriented x [times] 3 walking with assistance on Monday of last week [[DATE]], her granddaughter went to see her on Tuesday and Wednesday [[DATE] and [DATE]] when she noticed that she [Resident #4] is becoming confused and the family were informed by the NH [Nursing Home] that the patient fell down on Tuesday [[DATE]] and again on Friday [[DATE]] . Initial CT head reports an acute moderate to large sized right subdural hematoma [Acute subdural hematomas commonly form because of a severe head injury] with 1.5 cm [centimeter] right to left midline shift. She [Resident #4] was taken to the OR [Operating Room] by NSY [Neurosurgery] and underwent R [Right] FT [Frontal] craniotomy for evacuation of SDH [Subdural Hematoma] . Patient was admitted to ICU [Intensive Care Unit] for closer
monitoring and critical care management. She is now s/p [Status/Post] craniotomy on [DATE [2024]. Patient on AED [anti-epileptic drugs .as a prophylactic factor for post-traumatic seizures] prophylaxis. Repeat CTH [CT of the head] is stable .CONSULTATION XXX[DATE] .REASON FOR CONSULTATION . Acute on chronic right subdural hematoma as well as a left acute on chronic subdural hematoma .The patient will need intensive care unit level of care, q.1 h. [every one hour] neurological checks.

During an interview on [DATE] at 8:49 AM, the Director of Nursing (DON) reviewed each Resident #4 fall incident and was asked how she identified who performed the Neuro checks on [DATE]. The DON stated, . There is no name on the forms .you can’t tell . The DON was asked to review the fall incident for Resident #4 on [DATE] and on [DATE] and asked if the falls were witnessed or unwitnessed falls. The DON stated, Unwitnessed Fall . The DON was asked if the nursing staff should have documented and started Neuro checks and vital signs following the [DATE] and [DATE] falls. The DON stated, .Yes, ma’am . The DON was asked to review the fall incident for Resident #4 which occurred on [DATE] and asked if the Neuro Checks were complete. The DON stated, No it’s [the neuro checks] not . The DON was asked to review the unwitnessed fall for Resident #4 which occurred on [DATE] and asked if the Neuro Checks and Vital Signs were completed according to the facility policy. The DON stated, .No, ma ‘ am . The DON was asked how the Neuro checks, and frequent vital signs should be taken. The DON stated, .Every 15 minutes times 4, every 30 minutes time 2, every hour times 2, and every 4 hours times 24 hours .

In summary, Resident #4 had a history of a Subdural Hematoma with craniotomy and was on a medication with a potential side effect of increased bleeding. The facility had a history of not completing the neurological checks for Resident #4’s previous unwitnessed falls. Resident #4 had an unwitnessed fall on [DATE] at 2:00 AM, the facility initiated neurological checks at 2:00 AM through 2:45 PM on [DATE]. The facility failed to complete the neurological checks for the 24-hour period and did not document the resident’s vital signs with each neurological check in accordance with the facility’s policy. The neurological checks that were performed revealed Resident #4’s speech was rambling. The neurological checklist was dated [DATE] at 2:00 AM, the nurse reported to EMS the neurological checks were initiated on [DATE] at 2:00 AM. The facility reported to EMS on [DATE] at 2:00 PM (when EMS arrived) Resident #4 had degraded (declined) since 2:30 AM and did not notify the Medical Director or seek emergency treatment until approximately 12 hours later. Resident #4 had a decline between [DATE] (after the last neurological check was performed) at 2:45 PM and when the Medical Director was notified on [DATE] at 2:13 PM, almost 36 hours after the unwitnessed fall on [DATE].