Health inspection·December 1, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, investigation reports, clinical records, and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of six residents reviewed (Resident 2), resulting in harm to Resident 2 due to a fall that resulted in a fracture. Findings include: The facility's policy regarding abuse and neglect, dated October 24, 2023, indicated that the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. That neglect was defined as the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 5, 2023, revealed that the resident sometimes understood, sometimes understands, and had diagnoses of spinal stenosis (a narrowing of the spinal canal in the lower part of your back) and contractures (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) of the muscles at multiple sites. The resident's care plan, dated June 7, 2020, revealed that she required an extensive assist from two staff for her bed mobility. A nursing note for Resident 2, dated November 26, 2023, at 10:33 p.m. revealed that at 9:00 p.m. the nurse was in room [ROOM NUMBER] and Nurse Aide 1 came out of room [ROOM NUMBER] and stated that he was performing care and when he rolled the resident, the resident rolled out of the left side of her bed between the two beds. Upon entering the resident's room, the resident was lying on her left side on her left arm. The resident was bleeding from her head. Pressure was applied, her head was cleaned, and an ice pack was applied. The resident stated that she had pain in her head, so Tylenol was administered per order. A nursing note for Resident 2, dated November 26, 2023, at 10:53 p.m., completed by the registered nurse, revealed that the resident was on the floor on the left side of her bed. She was lying on her left side in a fetal position. A small puddle of blood was on the floor coming from her head. A laceration was observed to the left side of her head right above her ear. Nurse Aide 1 stated that he was changing the resident's brief (independently) while she was in bed. When he rolled her onto her left side, she rolled out of bed onto the floor. The resident required the assistance of two staff with all care. The resident complained of a headache, and Tylenol was administered. The laceration was Page 1 of 3 395331 395331 12/01/2023 Mountain Laurel Healthcare and Rehabilitation Ctr 700 Leonard Street Clearfield, PA 16830

F 0600 cleansed with soap and water and measured 1.0 centimeter (cm) by 0.1 cm by 0.1 cm., and ice was applied. Level of Harm - Actual harm Residents Affected - Few A nursing note for Resident 2, dated November 27, 2023, at 9:45 a.m., and completed by the registered nurse, revealed that the resident was complaining of head pressure and pain. The resident stated that if she does not move her neck the pain is better. The resident stated that moving the head of her bed up or down increases the pressure in her head. The Certified Registered Nurse Practitioner (has advanced education and clinical training in a health care specialty area) was notified and assessed the resident. An order was placed to send to the resident to the emergency room. A nursing note for Resident 2, dated November 27, 2023, at 2:00 p.m. revealed that the writer spoke with the resident's daughter, and she reported that her mother was being transferred to another hospital to see neurosurgery (surgery of the nervous system) for a C2 fracture (a break in the second vertebra of the neck). It was confirmed with the emergency room that the resident will be transferred to another hospital and that the resident has a C2 fracture. Nurse Aide documentation for Resident 2, dated November 2023, revealed that Nurse Aide 1 documented as providing care to Resident 2 on November 3, 7, 11, 13, 15, 16, 17, 20, 21, 22, 25, and 26, 2023. The facility's investigation, dated November 26, 2023, revealed that at 9:00 p.m. the nurse was in room [ROOM NUMBER] and Nurse Aide 1 came out of room [ROOM NUMBER] stating that he was performing care and when he rolled the resident she rolled out of the left side of her bed between the two beds. An investigation statement by Nurse Aide 1, dated November 26, 2023, revealed that he was holding Resident 2 while cleaning her up in bed and she slipped through his hands off the bed and hit the floor. He did not ask for help. The investigation determined that Nurse Aide 1 did not ask for assistance from another staff member when providing care to Resident 2 while she was in bed. A Corrective Action Form for Nurse Aide 1, dated November 27, 2023, revealed that while performing care to Resident 2 the resident rolled out of bed and onto the floor causing a hematoma and laceration to left side of her head. The resident later became neurologically (result from injury or changes to the functioning of the brain, spine, or nerves) comprised and was transferred to the emergency room, with a C2 fracture noted on CT scan. Resident 2 is care planned for extensive assistance of two staff for bed mobility, and Nurse Aide 1 performed care alone. Nurse Aide 1 had previously been educated for using a mechanical lift without a second staff member and for care not performed by him. As a result of Nurse Aide 1's actions, termination will occur due to failure to follow the care plan and facility policy and procedure. An interview with the Director of Nursing on December 1, 2023, at 1:48 p.m. confirmed that Nurse Aide 1 had taken care of Resident 2 previously and was familiar with the resident's care, and confirmed that he provided care by himself and that there should have been two staff present when caring for the resident, and that neglect was substantiated. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 395331 Page 2 of 3 395331 12/01/2023 Mountain Laurel Healthcare and Rehabilitation Ctr 700 Leonard Street Clearfield, PA 16830

F 0600 28 Pa. Code 211.12(d)(1)(5) Nursing services. Level of Harm - Actual harm Residents Affected - Few 395331 Page 3 of 3