Health inspection·August 15, 2023

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 a review of clinical records, select facility policy, investigative reports and information submitted by the facility, and staff and resident interviews it was determined that the facility failed to provide necessary set-up assistance with activities of daily living to prevent an accident resulting in minor injury to one resident out of three sampled (Resident 133). Findings include: A review of facility policy entitled Safety of Hot Liquids, revised October 2014, revealed that the potential for burns from hot liquids is considered a ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. Residents identified with risk factors for injury from hot liquids will have appropriate interventions implemented to minimize the risk from burns. Such interventions may include, staff assistance with hot beverages as needed. A review of Resident 133's clinical record revealed that the resident was admitted to the facility July 20, 2023, with diagnoses of depression, gastro-esophageal reflux disease (GERD), transient ischemic attack (TIA) and cerebral infarction (stroke) without residual deficits, mild vascular dementia, muscle weakness, abnormal posture, and lack of coordination. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated July 27, 2023, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 12 (8 - 12 represents moderate cognitive impairment) and required extensive assist of 2 staff members for bed mobility, transfers, dressing, toileting, personal hygiene (combing hair, brushing teeth), and was independent for eating after set up help. A review of the resident's baseline care plan initially dated, July 21, 2023, revealed that the resident has an activities of daily living (ADL) self-care performance deficit related to cerebral vascular accident/transient ischemic attack (CVA/TIA. The care plan noted the planned intervention/task to assist the resident with eating. The care plan indicated that the resident was independent with eating, but staff were to offer assistance with meal set-up, especially hot liquids, date initiated July 21, 2023, to provide a Kennedy cup (a lightweight spill proof drinking cup), with lid at meals to be utilized with hot liquids, initiated July 24, 2023. A nurses' note dated July 24, 2023, at 10:38 AM, indicated that the resident spilled tea on self and was complaining of burning on her legs. Nurse checked residents' legs for red areas from tea and Page 1 of 3 395464 395464 08/15/2023 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0689 none were noted. The resident was c/o burning where the lidocaine patch is, so the nurse removed the lidocaine patch and cleansed the area. Level of Harm - Actual harm Residents Affected - Few A nurse's note dated July 24, 2023, at 11:05 AM, indicated that after cleansing the area where the lidocaine patch was, the area was slightly red on the resident's left hip. After cleaning the area and applying ice the resident stated it felt better. Nursing noted, July 24, 2023, at 12:00 PM, as a late entry, skin assessment completed of a new skin alteration. Per staff and resident, the resident was removing a lid from cup of tea when liquid spilled it on her left lateral thigh below, Lidocaine patch that was placed this AM. Upon removal of patch resident was noted to have 2.4 cm x 2.2 cm area of non-blanchable pink skin with small clear fluid blister consistent with partial thickness burn. Dr. notified, new order received and noted. A physician order dated July 25, 2023, at 4:45 PM, was noted for Silver Sulfadiazine (a cream) apply to left thigh topically every day and evening shift for wound care for 6 days. Review of information dated July 24, 2023, submitted by the facility indicated that the resident was provided a [NAME] Cup for liquids, the temperatures of the tea on the trayline, prior to service, was 155 degrees Fahrenheit for breakfast, lunch 150, and dinner 145. Staff education was completed for all staff to open lids on the resident's liquids. A review of facility incident investigation dated July 24, 2023, at 12:10 PM, revealed that the resident spilled tea on herself. Staff education was provided regarding assisting resident tray set up at mealtimes. A review of the staff education dated July 26, and July 27, 2023, revealed that staff are to assist the resident with tray set up at mealtimes. This includes opening ALL cups/lids, condiment packets, straws, milk cartons and preparing tea/coffee per resident preference. The resident utilizes adaptive drinking equipment (Kennedy cups, nosy cups, two handled cups with lids, etc.) that liquids are placed in cups (especially hot liquids). At the time survey ended, August 15, 2023, the investigation had no staff witness statements regarding the event provided to the surveyor. During survey on August 15, 2023, the hot water temperatures for on the trayline, prior to meal delivery to residents, was 152 degrees Farenheit at Breakfast and lunch 156 degrees Farenheit. Interview with Resident 133, on August 15, 2023, at approximately 11:30 AM, indicated that staff served her meal tray on the day she spilled the tea on herself, but did not set it up for her as required. She attempted to remove the lid from her beverage (tea) and in doing so spilled the hot tea onto herself. According to the resident, this hot liquid had somehow activated the lidocaine patch that was already on her thigh and created a painful burning sensation. Observation of Resident 133's left thigh on August 15, 2023, at approximately 11:42 AM, with the resident's permission, in the presence of Employee 1 Registered Nurse (RN), revealed 2 small areas on the left lateral thigh one white softened area measuring 0.8 x 1.2 cm, and 0.5 x 1.0 cm, encircled by a reddened area measuring 3 cm x 2 cm, without odor or drainage, as measured by Employee 1. The second area had a white - softened center measuring 0.6 cm x 1.0 cm, encircled by a reddened area measuring 1.5 x 1.8 cm, without odor or drainage, as measured by Employee 1. 395464 Page 2 of 3 395464 08/15/2023 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0689 Level of Harm - Actual harm During interview on August 15, 2023, at approximately 2:15 PM, the Nursing Home Administrator (NHA) confirmed that the facility failed to provide the resident with necessary staff assistance to set up the resident's meal tray as required to prevent an accident and minor injury to the resident. Residents Affected - Few 28 Pa. Code (d)(3)(5) Nursing services 395464 Page 3 of 3