§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
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Observations:
Based on review of facility documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of three residents (Resident R1).
Findings include:
Review of facility policy "Neurological Assessment" last reviewed 2/20/25, indicated the purpose of the policy is to provide guidelines for a neurological assessment following an unwitnessed fall or subsequent to a fall with a suspected head injury. It was indicated to perform neurological checks with the frequency as ordered or per falls protocol. Document the date and time the procedure was performed, the name and title of the individual(s) who performed the procedure, all assessment data obtained, and the signature and title of the person recording the data.
Review of the facility's undated "Neurological Check Flowsheet" indicated to document the date and time of each neurological check. The frequency unless specified my physician is every 15 minutes x4, every hour x2, and every four hours x4.
Review of the clinical record indicated Resident R1 was admitted to the facility on 12/20/24.
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/9/25, indicated diagnoses of malnutrition, non-Alzheimer's dementia, and adult failure to thrive.
Review of Resident R1's progress note dated 12/12/25, revealed the resident was observed at 11:20 a.m. in front of door lying on right side of body. Bleeding noted to right frontal area previous area from prior fall. Area cleansed with normal saline solution (wound cleanser) bleeding stopped without difficulty. The resident was assessed by Nurse Practitioner, Employee E1. The resident's family and hospice were notified. The hospice physician ordered the resident to be sent to hospital for further evaluation of a head injury.
Review of the resident's clinical record on 12/12/25, failed to reveal evidence neurological checks were performed after the resident had an unwitnessed fall.
Review of Resident R1's progress note dated 12/12/25, at 1:04 p.m. revealed the resident was transferred to the hospital for further evaluation.
During an interview on 2/11/26, at 10:38 a.m. the Director of Nursing (DON) confirmed there was no evidence the facility initiated neurological checks after Resident R1 had an unwitnessed fall on 12/12/25.
During an interview on 2/11/26, at 12:27 p.m. the Nursing Home Administrator confirmed that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of three residents (Resident R1).
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 03/12/2026
R1 was sent to the ER for a CT scan. The CT scan results were negative, and the resident returned to the facility. The residents had no negative outcomes documented.
DON or designee will audit unwitnessed falls for the last 2 weeks to determine if neurological assessments were initiated and completed according to policy. DON will provide feedback to staff who did not follow policy.
DON or designee will In-service licensed staff on the facilities Neurological Assessment Policy. Facility practice will now include a designated form and location for neurological checks to be started by policy. Collection of documentation of neurological checks will be centralized and uploaded into the resident file.
DON or designee will audit unwitnessed resident falls to ensure that neuro checks are initiated and completed per policy. This audit will be completed 5 times per week for two weeks, 3 times per week for two weeks, and 1 time week for two weeks, and 1 time per month for 2 months.
Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.
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