Health inspection·February 9, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with standards of practice and physicians' orders regarding surgical site care which resulted in a failure of timely care for three of five residents (Residents R1, R2, and Closed Record CR1). Residents Affected - Few Findings Include: A review of the facility policy, Skin Assessment dated 4/26/23, indicated: -Non-pressure related skin conditions include but is not limited to skin tear, arterial ulcer, venous ulcer, foot problem, surgical wound, rash, cut, laceration, open lesion, or burn. -The licensed nurse will complete a head to toe skin assessment within two to six hours of admission/readmission to identify the presence of any skin issue. -If a non-pressure area is identified, will document a complete assessment on the N. Adv Skin Only Evaluation and reassess weekly until healed. -Describe the treatment order and response to treatment. Review of admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/31/24, indicated diagnoses of heart failure (a condition in which the heart doesn't pump blood as well as it should), high blood pressure, and left hip fracture. Section C indicated a Brief Interview for Mental Status (BIMS) score of 13 - cognitively intact. Review of Resident R1's Skin Only Evaluation dated 1/25/24, indicated post-surgical (after an operation) Aquacel (wound dressing) intact to left hip. Review of Resident R1's Skilled Evaluation V6.3 dated 2/1/24, indicated no skin issues. Review of Resident R1's Hospital Final Report document dated 1/25/24, indicated Aquacel dressing until post-op day seven. May shower. After post-op day seven clean wound with alcohol and apply 4x4 dressing and tape. Must cover for showers. Review of Resident R1's Treatment Administration Records (TAR) dated January and February 2024, Page 1 of 3 395034 395034 02/09/2024 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0684 failed to include physician orders for care and treatment of the left hip surgical wound. Level of Harm - Minimal harm or potential for actual harm Review of Resident R1's admission Physician's Order Summary dated 1/25/24, failed to include physician orders for care and treatment of the left hip surgical wound. Residents Affected - Few Interview on 2/8/24, at 12:15 p.m. Resident R1 indicated she had surgery on her left hip and they haven't changed the heavy plastic on her left hip since she arrived on 1/25/24. Observation on 2/8/24, at 12:16 p.m. Resident R1 pulled her trouser down an inch along the left hip displaying the top of the Aquacel dressing. Interview on 2/8/24, at 12:20 p.m. Registered Nurse (RN) Employee E1 indicated there was no order for the Aquacel dressing on Resident R1's hip and that it should have been removed seven days post-op around January 31, 2024, but there was no order put in for it. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Diagnosis Report dated 1/30/24, indicated the diagnoses of right hip fracture, heart failure, and repeat falls. Review of Resident R2's Clinical Admission document dated 1/30/24, indicated no skin issues. Review of Resident R'2's Hospital Discharge Summary dated 1/30/24, indicated to keep incision covered with clean, dry, occlusive (an air and water tight medical dressing). Review of Resident R2's admission Physician order summary dated 1/30/24, indicated keep right hip incision clean, dry with an occlusive dressing (dry gauze/opsite clear dressing) every morning. Review of Resident R2's TARs dated January and February 2024, failed to include physician orders for care and treatment of the right hip surgical wound. Interview on 2/8/24, at 12:35 p.m. the Director of Nursing indicated they failed to click the drop down box and schedule the order, therefore it did not show up on the TAR for the nurses to see. Review of the admission record indicated Resident Closed Record CR1 was admitted to the facility on [DATE]. Review of Resident CR1's MDS dated [DATE], indicated the diagnoses of heart failure, diverticulitis (inflammation or infection in small pouches in the digestive tract), and open wound of the abdomen. Review of Resident CR1's Skin Only Evaluation dated 1/2/24, indicated a 0.5 cm (centimeter) round open area on left lower quadrant draining a copious amount of brown, murky drainage. No odor. Review of Resident CR1's Hospital Final Report dated 1/2/24, indicated wound care/ostomy (surgical opening that allows bodily waste to pass through an opening on the skin) Discharge Recommendations: twice a day - left lower abdominal old JP (Jackson Pratt -surgical drain) drainage wound site. Cleanse with soap and water. Dry thoroughly. Apply critic aid clear (barrier paste) to surrounding wound. Apply a dry 4x4 gauze and Medipore 395034 Page 2 of 3 395034 02/09/2024 Vincentian Home 111 Perrymont Road Pittsburgh, PA 15237

F 0684 (flexible type of tape) tape to hold in place. Level of Harm - Minimal harm or potential for actual harm Review of Resident CR1's TAR dated January 2024, indicated the physician ordered treatment dated 1/6/24, of wound care for left lower abdominal old JP drainage wound site. Cleanse with soap and water. Dry thoroughly. Residents Affected - Few Apply critic aid clear (barrier paste) to surrounding wound. Apply a dry 4x4 gauze and Medipore (flexible type of tape) tape to hold in place. Review of Resident CR1's progress note dated 1/9/24, indicated the order for the dressing changes was entered into the system on January 5, 2024. Prior to that, Resident CR1 would regularly ask us to change the dressing. Interview with the Director of Nursing on 2/8/24, at 2:02 p.m. indicated that the order was not put in timely upon admission to the facility on 1/2/24, and that it was ordered on 1/6/24. Interview with the Director of Nursing and Nursing Home Administrator on 2/8/24 at 3:30 p.m. confirmed the facility failed to ensure that residents received treatment and care in accordance with standards of practice and physicians' orders regarding surgical site care which resulted in a failure of timely care for three of five residents (Residents R1, R2, and Closed Record CR1). 28 Pa Code: 201.29 (i) Resident rights. 28 Pa Code: 201.18 (b)(1)(3) Management. 28 Pa Code: 211.10 (c ) Resident care policies. 28 Pa Code: 211.12 (a )(d)(1)(2)(3)(5) Nursing services. 395034 Page 3 of 3