Health inspection·July 5, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and procedures, clinical record review, and staff interview, it was determined that the facility failed to notify the resident representative of a resident's transfer to the emergency room for one of four residents reviewed for notifications (Resident CR1). Findings include: A review of the policy titled Physician and Family Member Responsible Party Notification, last reviewed without changes in April 2023, revealed that the purpose was to maintain an open line of communication regarding the resident's condition between the resident, the resident's primary physician, responsible party, and facility. The policy noted that unless otherwise instructed by the resident, the facility will notify the resident's next of kin or responsible party when the resident is involved in any accident or incident that results in an injury, there is a significant change in the resident's physical/mental/psychosocial status, and/or it is necessary to transfer the resident to the hospital. Closed clinical record review for Resident CR1 revealed a comprehensive MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 1, 2023, which noted that staff assessed the resident as having cognitive impairment as evidenced by a BIMS (Brief Interview for Mental Status) score of 11. Closed clinical record review for Resident CR1 revealed nursing documentation dated March 17, 2023, at 3:47 PM that noted the resident went on a leave of absence to the [NAME] Life Center at 8:10 AM, was then taken to a cardiology appointment, and then admitted to the hospital with a diagnosis of atrial fibrillation (an irregular heart rhythm that can lead to blood clots in the heart). Hospital documentation dated March 17, 2023, at 9:56 AM revealed Resident CR1 has a surgical history of a pacemaker (an implanted device in the body to control the electrical impulses of the heart) and presented to the emergency room at the request of the pacemaker clinic due to tachycardia. The documentation further noted Resident CR1 went to the pacemaker clinic for a routine appointment. At the time of the arrival in the emergency room, the resident was tachycardic (a rapid heart rate) and was hypertensive (high blood pressure). The documentation noted the resident was admitted to the hospital due to atrial fibrillation with rapid ventricular rate (RVR). There was no evidence in the clinical record to indicate that Resident CR1's emergency contact was notified at the time of the transfer of the transport to the emergency room from the cardiology appointment. Page 1 of 2 395283 395283 07/05/2023 Oak Glen Healthcare and Rehabilitation Center 15 Ridgecrest Circle Lewisburg, PA 17837

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with the Nursing Home Administrator on July 5, 2023, at 10:57 AM revealed that nursing staff should have notified the appropriate contact of Resident CR1's transfer to the hospital. However, the Nursing Home Administrator further noted she believed it was the responsibility of the [NAME] Life Center to notify the emergency contact of the transfer to the emergency room since she went there prior to the appointment. The facility was unable to provide any documented evidence that the emergency contact was notified by either facility. The facility failed to notify Resident CR1's designated emergency contact of the transfer to the emergency room from a routine cardiology appointment. The above information was reviewed in an interview with the Nursing Home Administrator and Director of Nursing on July 5, 2023, at 3:00 PM. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa Code 211.12 (d)(3)(5) Nursing services 395283 Page 2 of 2