Health inspection·May 15, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on staff interviews and the review of the clinical record, it was determined that the facility failed to ensure that the physician was notified of a change in the resident's medical status for one out of four residents reviewed (Resident R1). Findings include: Review of the facility policy, Change in a Resident's Condition of Status, with a revision date of May 2021 indicated that the facility will notify the resident, his/or attending physician and the resident's representative of changes in the resident's medical/mental condition and/or status. Continued review of the policy indicated that the nurse will notify the resident's attending physician or the physician on call when incidents including, but not limited to the following has occurred with the resident: accident or incident involving the resident; discovery of injuries of an unknown origin; adverse reaction to medication; significant change in the resident's physical/emotional/mental condition; refusal of treatment for two or more consecutive times, or the need to transfer the resident out of the hospital. Review of the May 2024 physician orders for Resident R1 included the diagnosis of epilepsy (a brain condition that causes reoccurring seizures). Review of the resident's Annual Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated May 2, 2024, indicated that the resident was severely cognitively impaired. Review of a nursing note dated May 6, 2024 at 5:30 p.m. written by Employee E4 (licensed nurse) who worked 7:00 a.m. through the 3:00 p.m. nursing shift and worked 3:00 p.m. through the 11:00 p.m. nursing shift on May 6, 2024, indicated Received in report this morning resident was witnessed having a seizure by cna (nurse aide) lasting at least one min (minute). Review of the above referenced nursing note indicated that Resident R1 was assessed by Licensed nurse, Employee E4 after she was notified and Employee E4 documented that there were no issues with the resident throughout the duration of the 7:00 a.m. through the 3:00 p.m. shift. Continued review of the above-referenced nursing indicated that during dinner on May 6, 2024, during the 3:00 p.m. through the 11:00 p.m. nursing shift, Employee E5 who was also assigned to Resident R1 on this nursing shift, reported to Employee E4 that the resident did not look well during dinner. Review of the note indicated that the physician was notified, and ordered that Resident R1 be transported out to the hospital via 911. Review of the resident's nursing notes did not show evidence that the physician was notified during Page 1 of 2 395193 395193 05/15/2024 Rosemont Center 35 Rosemont Avenue Rosemont, PA 19010

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the 7:00 a.m. through the 3:00 p.m. shift after Employee E4 was notified by Employee E5 of a change in the resident's medical condition, when Employee E5 reported to Employee E4, that she witnessed the resident having a seizure that lasted lasting at least one minute in duration. Review of a nursing note dated May 10, 2024 at 5:02 p.m. documented that the resident returned from the hospital on the above reference date, and the resident's hospital admitting diagnosis was seizures. Review of resident's hospital documentation revealed, Discharge Summary, indicated that the resident had a breakthrough seizure (when an individual has a seizure after being seizure free for approximately 12 months). You were admitted to [hospital name] with a break through seizure. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on May 15, 2024 at 3:00 p.m. the ADON confirmed that Employee E4 did not notify the physician or any nursing staff (e.g. Unit manager/Nurse Supervisor on any of the shifts, Director of Nursing, Assistant Director of Nursing) of what Employee E5 reported to her about Resident R1 having a seizure on the 7:00 a.m. through the 3:00 p.m. shift. The DON reported during the above referenced interview that she was not notified of the resident having a seizure on the 7:00 a.m. through the 3:00 p.m. shift until approximately 5:00 p.m. when she received a phone call to notify her about the physician ordering the resident to go out to the hospital. 28 Pa. 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services 395193 Page 2 of 2