Health inspection·January 21, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation, and staff interviews, it was determined the facility failed to ensure adequate supervision of two staff members was provided during incontinence care to Resident R1. This failure resulted in actual harm to Resident R1 who fell out of bed and sustained a fracture of the left arm and a fracture of the left hip for one of seven residents reviewed. (Resident R1) Findings include: Review of facility policy titled Turning and Positioning, revised 2024, revealed assistance must be obtained in turning and repositioning residents/patients who require more than one-person assistance. Do not attempt to turn and reposition by yourself. During care, resident will be turned safely in bed, allowing for proper space to safely turn resident consistent with resident's plan of care. Clinical record review revealed Resident R1 was admitted to the facility on [DATE], with a diagnosis of Chronic Obstructive Pulmonary Disease (lung condition caused by damage of airways that limit airflow), lack of coordination, abnormalities of gait and mobility, and Dementia (progressive degenerative disease of the brain). Review of Resident R1's Minimum Data Set (MDS- mandated assessment of a resident's abilities and care needs) dated October 14, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Further review of Resident R1's MDS assessment under section G- Functional Status, revealed Resident R1 was assessed as requiring two plus person physical assist for bed mobility. Bed mobility in the MDS assessment is defined as how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Interview on January 21, 2024, at 3:00 p.m. with Employee E2, MDS Coordinator, revealed Resident R1 coded for a two plus person physical assist for bed mobility based on a look back period of nursing aides documentation. The doucmentation revealed Resident R1 required four out of seven days of two plus person physical assist for bed mobility. Review of Resident R1's care plan dated March 10, 2021 revealed Resident R1 had an ADL (Activities of Daily Living) self care performance deficit. Interventions related to bed mobility included assistance of two staff to turn and/or reposition. Review of Resident R1's nursing note dated December 28, 2024, at 7:38 p.m. indicated, This nurse Page 1 of 2 395346 395346 01/21/2025 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0689 Level of Harm - Actual harm Residents Affected - Few was notified by care aide while providing care to resident, resident rolled onto the floor, this nurse notified the nursing supervisor went into the room to assess the resident. Resident had a laceration to the LLE (left lower extremity), and placed a bandage over the site/ neuro checks started. MD (physician) notified. Continued review of nursing documentation dated December 28, 2024, at 8:17 p.m. revealed, Resident was in bed with a small cut on [his/her] left shin measuring 0.3cm (centimeters) x 0.3 cm Aide then reported the resident rolled out of bed when she turned [him/her] over to change [his/her] brief. Resident c/o (complaint/of) the left arm hurting [her/him]. The nurse assessed the area but no matter where I touched [her/him], [she/he] said it hurt. The on-call physician was notified and ordered x-rays of wrist, elbow, and shoulder to be done immediately. Review of nursing note dated December 29, 2024, at 5:33 p.m. revealed, at 7:00 p.m. x-ray results were received and revealed an oblique fracture neck of the the left humerus (arm) without dislocation, left wrist possible occult fracture of the med left radius, left hip suspicious for fracture intertrochanteric region left femur (hip) without dislocation. Review of nursing note dated December 30, 2024, at 7:48 a.m. revealed that Resident R1 was transferred to the hospital via 911 (Emergency Medical Services). Continued review of nursing documentation dated December 30, 2024 at 7:18 p.m. indicated the resident was admitted into the hospital with a diagnosis of proximal end of left humerus. Review of the facility's investigation into the fall incident sustained by Resident R1 included a typed statement form Nurse aide, Employee E3, which revealed, on 12/28/2024 I was providing care for the resident and asked [her/him] to roll on [her/his] side and as [she/he] turned [herself/himself] rolled out of bed. I called for the nurse. Interview with Nursing Home Administrator, Employee E1 conducted on January 21, 2024, at 12:30 p.m. revealed that Employee E3 was no longer working at the facility. Employee E3 was not available for interview. The facility failed to ensure adequate supervision of two staff members was provided to Resident R1 while turning/repositioning resident during incontinence care. This failure resulted in actual harm to Resident R1 who fell out of bed and sustained a fracture of the left arm and a fracture of the left hip. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395346 Page 2 of 2