Health inspection·March 19, 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 Based on clinical records review, and interviews with resident and staff interviews, it was determined that the facility failed to ensure an order for NPO (nothing per mouth) before a procedure was followed for one of the two residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility with a diagnosis of Atrial Fibrillation (irregular heartbeat), awaiting hip surgery, and Intellectual disability. Review of Resident R1's admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 3, 2024, revealed resident's cognition was intact. Review of the nursing progress notes dated February 22, 2024, at 2:39 p.m., revealed resident returned from a Cardiologist (A physician who specializes in heart conditions) appointment. The note revealed that the resident was scheduled for a Transesophageal Echocardiogram (TEE- An ultrasound that provides highly detailed images of the heart and its internal structure) on February 28, 2024, at [Hospital Name]. NPO 12 hours before the procedure. Review of the physician's order dated February 23, 2024, revealed an order for NPO at midnight, may take all morning medications on February 28, 2024, with water every shift until 10:00 a.m. review of the nursing progress notes dated February 28, 2024, at 3:35 p.m., revealed resident's echocardiogram will be rescheduled, nurse practitioner is aware. Interview with Resident R1 was conducted on March 19, 2024. Resident R1 reported that on the morning of February 28, 2024, a female staff came to her/his room and provided her/him with a breakfast tray. Resident R1 reported that she/he consumed a cup of orange juice and 2-3 spoons of cereal when the nurse came and told her/him about the NPO order. Resident R1 reported that she was previously made aware of the NPO order but forgot about it on the day of the procedure. Interview with licensed nurse Employee E3 was conducted on March 19, 2024. Employee E3 reported that she/he was the nurse working on the morning of February 28, 2024. Employee E3 reported that at around 7:00 a.m. while receiving a report from the previous shift, an agency nurse aide provided Resident 1 a breakfast tray. Employee E3 reported talking to the resident and was informed that she/he consumed a few sips of orange juice. The doctor/procedure place was notified and ordered to reschedule the echocardiogram. Page 1 of 2 395078 395078 03/19/2024 Pine View Healthcare and Rehabilitation Center 50 North Malin Road Broomall, PA 19008

F 0684 Level of Harm - Minimal harm or potential for actual harm interview with the Director of Nursing was conducted on March 19, 2024. The DON reported that for NPO orders, a communication form is sent to the kitchen. The facility was unable to provide documented evidence that a communication form was sent to the kitchen informing Resident R1 was NPO on February 28, 2024, until 10:00 a.m. Residents Affected - Few The facility failed to ensure the NPO order was followed resulting in delay of Resident1's TEE procedu 28 Pa. Code 211.5(f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services 395078 Page 2 of 2