Saint John Paul Ii Center

Review of facility cardiopulmonary resuscitation (CPR) policy; in part, identified if a patient does not have a do not resuscitate order (DNR), CPR certified staff will initiate CPR and emergency medical services (EMS) will be activated. CPR should also be discontinued when a provider, including a nurse (RN) or nurse practitioner (NP) pronounces death provided they have the authority to do so.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Saint John Paul II Center

33 Lincoln Avenue Danbury, CT 06810

SUMMARY STATEMENT OF DEFICIENCIES

5:20 AM, 5:50 AM, 6:20 AM and 6:50 AM, LPN #2 documented Resident #2 was asleep, and had stopped evaluating Resident #2's neurological status.

The neurological evaluation flow sheet was completed again at 7:20 AM on 7/20/25 at 7:20 AM to 2:00 AM on 7/21/25 indicating Resident #2's neurological status was assessed.

Interview with RN #1 on 8/21/2025 at 11:12 AM identified on 7/22/25 at approximately 2:50 AM, LPN #1 notified him Resident #2 had a fall and was lying on the floor in his/her room. RN #1 indicated when he entered the room Resident #2 was lying on his/her back on the floor next to the bed and Resident #2 was alert and responsive, denied hitting his/her head, denied any pain, and no injuries were noted. RN #1 identified he assessed Resident #2's neurological status, Resident #2's neuros were within normal limits, and initiated neuro checks.

Interview with the 11PM-7AM nurse aide, Nurse Aide (NA) #4, on 8/21/25 at 11:19 AM identified on 7/22/25 at approximately 2:50 AM, LPN #2 yelled to her to come down to Resident #2's room. NA #4 identified when she entered the room Resident #2 was on his/her back lying on the floor next to the bed with his/her head next to the bottom of the bed. NA #4 indicated Resident #2 was alert, awake, and talking and after RN #1 assessed Resident #2, they assisted Resident #2 back into bed using a mechanical lift.

Interview with LPN #2 on 8/21/25 at 11:30 AM on 7/22/25 at approximately 2:50 A.M. Resident #2 was yelling out for help, so she ran down to the room and observed Resident on his/her back on the floor next to his/her bed with his/her head at the bottom of the bed. LPN #2 indicated she notified RN #1 who came to assess Resident #2 and no injuries were noted. LPN #2 identified Resident #2 was assisted back into bed by RN #1 and the nurse aides via a mechanical lift. LPN #2 identified she evaluated Resident #2's neurological status every fifteen (15) minutes from 2:50 AM until 4:50 AM but at approximately 5:20 AM Resident #2 fell asleep, so she did not wake Resident #2 up the remainder of her shift to evaluate Resident #2's neurological status and left at 7:00 AM.

Interview and clinical record review with the Director of Nursing (DON) on 8/21/25 at 1:25 PM identified her expectations are anytime a resident has an unwitnessed fall neurological evaluations are initiated and conducted per the frequency on the neurological flow sheet until complete.

The DON identified on 7/20/25 when Resident #2 was sleeping, LPN #2 should have woken up Resident #2 and assessed Resident #2's neurological status.

Although requested, a facility neurological assessment policy was not provided.

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