Health inspection·November 1, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policies, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to maintain complete and accurate records for three of 12 residents reviewed (Residents R1, R2, and R3). Findings include: Review of a facility policy entitled Resident Incident Reporting indicated that: all resident incidents are identified and tracked for compliance to assure follow-up on all resident incidents and provide treatment as appropriate; at the time of the incident staff will complete the Resident Incident Report including family/physician notification; all incidents are reviewed and care planned; and incidents are forwarded to the Director of Nursing (DON), Administrator (NHA), and Medical Director (MD) for review and comments if applicable. Review of Resident R1's clinical record revealed an admission date of 2/22/22, with diagnoses that included brain injury, epilepsy (brain disorder that causes recurring, unprovoked seizures), inability to speak, tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and quadriplegia (paralysis that affects all a person's limbs and body from the neck down). The clinical record also revealed a physician's order dated 9/18/23, at 11:50 p.m. to obtain an x-ray of the left pointer finger as soon as possible. Review of Resident R1's departmental progress notes revealed that on 9/19/23, at 8:17 a.m. staff Licensed Practical Nurse (LPN) documented discussed with second shift supervisor left pointer finger swollen, bruised, and possibly broken; at 11:00 a.m. x-ray to left pointer finger as soon as possible to rule out fracture, and may apply ice to finger; and at 2:11 p.m. an x-ray obtained at 11:30 a.m. Review of Resident R1's x-ray results dated 9/19/23, at 11:52 a.m. revealed no fracture nor dislocation of the left pointer finger. Further review of Resident R1's clinical record revealed lack of evidence that an investigation was initiated for an injury of unknown origin, or that the resident's representative was notified of the change in condition/injury and possible fracture. During an interview on 11/01/23, at 12:30 p.m. the Assistant Director of Nursing (ADON) and Administrator (NHA) confirmed that there was not evidence that an investigation was initiated or that Resident R1's family was notified of the injury and that there should have been an investigation initiated and notification to family. Page 1 of 2 395361 395361 11/01/2023 Pleasant Ridge Manor East/West 8300 West Ridge Road Girard, PA 16417

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident R2's clinical record revealed an admission date of 8/24/20, with diagnoses that included Alzheimer's Disease, obsessive-compulsive behavior (unreasonable thoughts and fears [obsessions] that lead to compulsive behaviors), difficulty walking, and restlessness/agitation. Review of an investigation dated 10/17/23, and provided by the facility on 11/01/23, indicated that staff discovered a bruise on Resident R2's right calf. There was no evidence that the physician and family were notified of the bruise. Review of Resident R2's departmental progress notes lacked follow-up assessments/treatments, and that notifications were made to the physician and family. Review of Resident R3's clinical record revealed an admission date of 6/03/21, with diagnoses that included epilepsy, dementia, wandering, and rhabdomyolysis (serious medical condition that can be fatal or result in permanent disability). Review of an incident investigation initiated 10/11/23, and provided by the facility on 11/01/23, lacked documentation of components of the investigation to include the type of incident, injury, assessment, treatment, follow-up actions, and notifications. Review of Resident R3's departmental progress notes lacked follow-up assessments/treatments, and that notifications were made to the physician and family. During an interview on 11/01/23, at 12:41 p.m. the ADON confirmed that Resident R3's clinical record lacked documentation related to lacked follow-up assessments/treatments, and notifications were made to the physician and family and additionally, during an interview on 11/01/23, at 1:02 p.m. the ADON confirmed there was no evidence that staff documented follow-up assessments and notified Resident R2's family of the bruise. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395361 Page 2 of 2