Health inspection·January 27, 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 Based on clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that interventions were put into place to prevent accident hazards during a transfer, resulting in actual harm as evidenced by a skin tear requiring treatment, for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), abnormalities of gait and mobility, and muscle weakness. Review of nursing progress notes entered by Employee 1 (Registered Nurse) dated January 16, 2025, revealed that she was called to Resident 1's bedside to assess a skin tear that was acquired while transferring Resident 1 into bed. Further review of the note revealed, Two aides present, transferring resident d/t [due to] resident dislodging hoyer pad from correct positioning. During transfer right forearm sustained a 9 cm x 11.5 cm long skin tear. Bleeding controlled. Area cleansed. Per ADON [Assistant Director of Nursing], Xeroform, ABD, kling wrap [types of wound dressings] applied. Review of Resident 1's current and active physician orders revealed an order for a transfer status of two assist with a full mechanical lift, effective December 17, 2024. Review of Resident 1's care plan that was in place at the time of the incident on January 16, 2025, revealed a care plan related to his impaired functional status with an intervention of a two-person assist using a hoyer lift for transfers. Review of Employee 2's (Nurse Aide) witness statement obtained by Human Resources on January 20, 2025, revealed, [Employee 3 - Nurse Aide] took resident to room and asked [Employee 2] to assist with the transfer. He noticed the Hoyer Pad was wedged under his bottom so they could not do a Hoyer Lift. [Employee 2] stated they were both on the same page and decided to do a stand/pivot transfer due to safety concerns. [Employee 3] put the Broda [type of wheelchair] next to the bed. [Employee 3] was watching from the opposite side of the bed when [Employee 2] transferred the resident by himself. He put both arms under the resident's armpits and lifted the resident by himself. The resident's arms were on his waist. He heard the resident yell and pivoted him to the bed . When asked why he did it by himself, he stated that it was easier to do that. He also stated that it was safer. When he [the resident] sat down [Employee 3] looked at his arm and saw blood saturated through his sweatshirt. [Employee 2] stated the resident was noncombative. Once in bed, [Employee 3] rolled his sleeve back Page 1 of 3 395375 395375 01/27/2025 Swaim Health Center 210 Big Spring Road Newville, PA 17241

F 0689 and saw the skin tear. [Employee 2] went to get the nurse to look at the skin tear. Level of Harm - Actual harm During an interview with Employee 2 on January 27, 2025, at 10:26 AM, he stated that on the date in question, Employee 3 took Resident 1 to his room. She asked Employee 2 for assistance, and he agreed. Once he arrived in the room, they discovered that Resident 1's lift pad was not properly positioned under his bottom. Employee 2 stated that both he and Employee 3 knew that Resident 1 was to be transferred with a lift, but they knew they had to do something else. Employee 2 states that he transferred Resident 1 by himself. During the transfer, Employee 3 was on the other side of the bed, but was paying attention enough to help if needed. Employee 2 stated that he did a stand/pivot transfer with Resident 1's arms around his waist. After he stood Resident 1 up, Resident 1 screamed. Employee 2 stated he then sat Resident 1 down on his bed. That's when they noticed the injury and went to get the nurse. Employee 2 stated that he had never encountered the situation before where a lift pad was not positioned where it was useable, and he just used his best judgement at the time. He acknowledged that he was aware that Resident 1 was to be transferred with a lift. Residents Affected - Few Review of Employee 3's witness statement, obtained by the ADON, Employee 6 (Registered Nurse Unit Manager), and Human Resources on January 20, 2025, revealed, [Employee 3] stated that she had placed the Resident in his room by his bed, between his bed and the roommate's bed. [Employee 3] stated that she went to get [Employee 2] to help her. [Employee 3] stated she walked away, to get gloves on prior to the transfer. [Employee 3] stated as she turned around, [Employee 2] had stood the Resident to transfer him into his bed .[Employee 3] admitted she did not assist with the transfer; however, she watched the transfer occur. She stated [Employee 2] had his arms positioned under the resident's armpits, and the Resident put his arms around [Employee 2's] neck. [Employee 3] stated that the Resident stated ouch as he was placed in a sitting position on his bed. [Employee 3] stated they laid the Resident on his back, when [Employee 3] noted the Resident's right sleeve was saturated with what she assumed was blood. [Employee 3] also stated that she pulled the Resident's sleeve back to see what was wrong with the Resident's right arm .[Employee 3] saw the skin tear on Resident's right forearm and had [Employee 2] go get the Nurse [Employee 3] stated, they told the nurses, that her and [Employee 2] both transferred the Resident. [Employee 3] also admitted that she told a CNA [Certified Nurse Aide], Friday 1/17/25, the real story of what occurred .During the re-enactment of the incident in the Resident's room, [Employee 3] admitted that she stood on the opposite side of the bed and watched [Employee 2] transfer the Resident by himself and did not help nor ask him to stop. [Employee 3] was asked why they were standing and pivoting the Resident instead of using the mechanical lift per care plan. She said the sling was scrunched up under the Resident's bottom. [Employee 3] was asked why they did not stand and fix the sling, she stated, I didn't think of that. Review of wound consult dated January 20, 2025, revealed that Resident 1's right forearm skin tear was assessed on that date, and it was noted that a moderate amount of serosanguinous exudate (wound drainage), and FLACC pain level of 3 (1-10 scale used to assess pain of individuals unable to verbalize pain levels) was present at the time. Orders were given for a wound dressing to be applied twice per day and as-needed. During an interview with the Nursing Home Administrator (NHA) on January 27, 2025, at 10:45 AM, she revealed that she would have expected Employee 2 and 3 to stand Resident 1 and fix his lift pad, or seek assistance from a nurse. During an interview with the Director of Nursing (DON) on January 27, 2025, at 11:40 AM, she revealed that nursing staff were educated in November 2024 about following the care plan, and that failure to do so could rise to the level of neglect. She also revealed that transfer status was 395375 Page 2 of 3 395375 01/27/2025 Swaim Health Center 210 Big Spring Road Newville, PA 17241

F 0689 specifically reviewed during this training, and staff were instructed to seek help if they have questions about transfer statuses. Level of Harm - Actual harm The facility's corrective action was reviewed during the onsite survey. Residents Affected - Few After the investigation, the facility terminated both Employees 2 and 3. On January 20, 2025, the DON completed a review of incident reports for the previous 30 days to determine negative outcome from failure to follow the Resident's care plan. The finding were negative. On January 20, 2025, a full sweep of all residents was completed to ensure that each had an accurate transfer status noted on their care plan. Review of education dated January 17 - 23, 2025, revealed that nurse aides, licensed staff, and therapy staff were educated on abuse and neglect, and the facility's Transfer of a Resident policy. Ongoing audits were initiated on January 20, 2025, and are to continue three times per week for one month, then weekly for one month, then monthly for three months. The results are to be reviewed at the Quality Assurance and Performance Improvement Committee. Review of the audits revealed they are monitoring if appropriate transfer status was used by staff, and if a mechanical lift was utilized properly, if applicable. Review of the facility's education, audits, and staff interviews revealed no concerns. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395375 Page 3 of 3