Health inspection·July 30, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). Findings: Review of facility policy Documentation in Medical Record indicated each resident's medical record shall contain an accurate representation of the actual experience of the resident. Documentation shall be factual, objective, and resident centered. Documentation shall be accurate, relevant, and complete. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, anxiety, and diabetes. Review of the clinical record Blood Pressure Summary revealed documentation of the following: On 7/1/24, at 6:36 a.m. 126/78 (lying r/arm). Indicating Resident R1's position, and where the blood pressure was taken. On 6/20/24, at 12:55 p.m. 137/55 (sitting r/arm). On 6/12/24, at 10:22 p.m. 128/70 (lying r/arm). On 6/12/24, at 4:20 p.m. 136/72 (lying r/arm). Review of a progress note dated 6/10/24, at 9:55 p.m. indicated on admission resident had a right AV Fistula (a connection that's made between an artery and a vein for dialysis access). A progress note dated 6/24/24, at 12:42 a.m. indicated that at 10:30 p.m. the nurse was notified of Resident R1 having swelling in her right arm, with decreased bruit and thrill (rumbling or swooshing sound of a dialysis fistula bruit is caused by the high-pressure flow of blood through the fistula and felt through the skin). During an interview on 7/30/24, at 12:12 p.m. Registered Nurse (RN) Employee E1 stated if resident's have an access site (PICC, IV, Fistula, graft, etc.) on their body, that body part is not to be used for blood pressures or blood draws. The facility does not hang signs in the residents rooms due to privacy. Page 1 of 2 395032 395032 07/30/2024 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/30/24, at 12:20 p.m. RN Employee E2 stated she would not use the PICC/IV/fistula arm for blood pressures or blood draws. She was the nurse that documented the use of the right arm for blood pressures on 6/20/24. She stated she knows for sure that she did not use the right arm for blood pressures. RN Employee E2 stated she also works for at a dialysis center on Monday-Wednesday-Friday's and knows not to do that. She stated Resident R1 was very alert and would make sure to tell staff not to use that arm, she was very adamant about it. RN Employee E2 states it was a documentation error on her part, body parts are listed in a drop-down box when charting vitals, and she must have scrolled to the wrong arm. During an interview on 7/30/24, at 1:00 p.m. the DON stated the right arm swelling started on 6/24/24, and the resident was sent to the hospital for evaluation. During a telephone interview on 7/30/24, at 2:44 p.m. RN Employee E3 stated she remembered Resident R1 and the resident would tell her which arm to use. She was also a staff member who documented using right arm for blood pressures. She stated it was a documentation error. During a telephone interview on 7/30/24, at 2:47 p.m. RN Employee E4, stated she knows for a fact that she did not use Resident R1's right arm because her mother receives dialysis treatments and she knows how important the fistula limb is. She is listed as a staff member that documented using the right arm. She stated it was a documentation error. During a telephone interview on 7/30/24, at 2:49 p.m. Licensed Practical Nurse Employee E5 stated she remembers taking Resident R1 ' s vital signs in the left arm. She is listed as a staff member that documented using the right arm. She stated it was a documentation error. During an interview on 7/30/24, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure documentation was accurate and complete for Resident R1. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(5) Nursing services. 395032 Page 2 of 2