Health inspection·July 8, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on facility policy review and clinical record review, it was determined that the facility failed to notify a resident's physician of changes in clinical condition for one of three sampled residents. (Resident 3) Residents Affected - Few Findings include: A review of the facility policy entitled, Notification of Changes, last reviewed November 1, 2023, revealed that staff were to notify the physician and resident representative if there was a change in clinical condition. Clinical record review revealed that Resident 3 had diagnoses that included dementia, difficulty walking, and osteoporosis. According to the pain evaluation documentation during May 2024, the resident had either no pain or a pain rated as a 1 on a scale of one to ten. On May 13, 2024, at 7:30 p.m., a nurse noted that the resident fell and was found on her left side. That night at 11:17 p.m., a nurse noted that the resident's pain was rated a 3. The following morning at 6:03 a.m., the nurse noted that the pain level increased to a 6. At 7:18 a.m., the nurse noted that the resident was having pain in her left hip when she moved. There was no documentation that the facility notified the resident's physician of the increase in hip pain following the fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 2 395409 395409 07/08/2024 Liberty Pointe Rehabilitation and Healthcare Ctr 252 Belmont Avenue Doylestown, PA 18901

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to evaluate effectiveness of pain medication consistent with professional standards for one of three sampled residents. (Resident 3) Residents Affected - Few Findings include: Review of the facility policy entitled, Pain Management, Last reviewed November 1, 2023, revealed that when using medications to treat pain, nursing staff was to evaluate the effectiveness of the medication to ensure appropriate treatment. Clinical record review revealed that Resident 3 had diagnoses that included dementia, difficulty walking, and osteoporosis. Since September 24, 2021, the resident had an ongoing physician's order that staff administer a pain medication (acetaminophen 650 milligrams) as needed for mild pain (pain rated 1-3 on a scale of 1-10). On May 13, 2024, at 7:30 p.m., a nurse noted that the resident fell and was found on her left side. According to the Medication Administration Records (MARs), that night at 10:23 p.m., a nurse administered the acetaminophen for pain rated at a 3. There was no documentation that the nurse assessed the resident afterwards to determine if the medication was effective. Documentation on the MAR the following morning at 6:03 a.m., indicated that the resident's pain had worsened to a 6. The nurse again administered the acetaminophen despite the pain being more severe than mild. Additionally, there was no evidence that the nurse notified the physician to obtain orders for additional pain management appropriate to the severity of the resident's pain. During an interview on July 8, 2024, at 1:30 p.m., the Director of Nursing confirmed that nursing staff should have documented whether or not the pain medication was effective. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395409 Page 2 of 2