Health inspection·December 27, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, closed clinical record, and staff interview, it was determined that the facility failed to notify a medical provider of a change in a resident's condition for one out of four residents reviewed (Resident CR1). Findings include: A review of the facility policy titled, Change in a Resident's Condition or Status, revealed a policy statement that noted the facility should promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The policy further noted the nurse will notify the resident's attending physician or physician on call when there is a significant change in the resident's physical condition, need to alter the resident's medical treatment significantly, and/or specific instructions to notify the physician of changes in the resident's condition. A review of the facility policy titled, Oxygen Therapy, revealed that a physician must order the oxygen therapy. There were no instructions in the policy related to the titration (assess oxygenation and adjust the rate based on resident response to the treatment) of oxygen therapy. A review of the facility policy for bi-level positive airway pressure (BiPAP, is a non-invasive ventilation machine that can generate two adjustable pressure levels - Inspiratory Positive Airway Pressure (IPAP) high amount of pressure, applied when the patient inhales and a low Expiratory Positive Airway Pressure (EPAP) during exhalation). The policy noted that Bi-level also known as Bi-PAP must be ordered by a physician. There were no instructions in the policy related to troubleshooting the device or what actions to take if there are problems encountered (such as a mask leak). Closed record review for Resident CR1 revealed the resident was admitted to the facility on [DATE]. The resident had a diagnosis list that included: chronic respiratory failure with hypoxia (low oxygen levels in the body), chronic respiratory failure with hypercapnia (abnormal levels of carbon dioxide in the body), chronic obstructive pulmonary disease (COPD, a lung disease caused by obstructed airflow and breathing difficulties), sleep related hypoventilation (breathing that is not sufficient during sleep that may include breathing too shallow or too slow), chronic pulmonary edema (abnormal fluid accumulation in the lungs), and heart failure (the heart has difficulty pumping blood). Page 1 of 3 395482 395482 12/27/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Physician orders for Resident CR1 included an order dated [DATE], that instructed staff to monitor each shift for shortness of breath while lying flat and this was documented on the Medication Administration / Treatment Administration Records (MAR/TAR) by staff by indicating Y for yes or N for no. Additional physician orders for Resident CR1 dated [DATE], included BiPAP via mask every evening and night shift related to sleep related hypoventilation and an order dated [DATE], for oxygen at four liters per minute via nasal cannula (a type of medical tubing to deliver supplemental oxygen to the nose) continuously. Review of Resident CR1's care plan revealed the resident had an altered cardiovascular status related to their medical history. An intervention included to obtain vital signs as ordered and notify the physician of any abnormal readings. Further review of Resident CR1's care plan revealed the resident had an altered respiratory status related to their medical history. An intervention included: monitor for signs/symptoms of respiratory distress and report to the physician as needed (which included a decreased pulse oximetry). MAR/TAR documentation dated [DATE], for the night shift, revealed that staff documented y for yes to indicate Resident CR1 was having shortness of breath while lying flat. Nursing documentation dated [DATE], at 12:45 AM revealed that Resident CR1 was calling out and his SpO2 (oxygen saturation, the amount of oxygen carried by the blood and measured with a non-invasive medical device that is usually placed on a finger; normal readings are typically between 92 percent and 100 percent) was .only in the high 70s with BiPAP in place. The documentation noted the mask was leaking a lot of air from sides, and the staff were unable to get the mask to stop leaking. The nurse attempted to apply oxygen via nasal cannula at five liters per minute and the resident was mouth breathing and the SpO2 remained unchanged. Staff then applied oxygen at six liters per minute via mask and the SpO2 improved to 99 percent and the resident was satisfied with wearing the oxygen via mask. Interview with the Director of Nursing on [DATE], at 12:35 PM revealed that the mask noted in the above documentation referred to a simple mask (a mask that fits over the mouth and nose to deliver supplemental oxygen). MAR/TAR documentation dated [DATE], at 1:06 AM revealed a Medication Administration Note that indicated the resident was 95 percent on six liters oxygen via mask. MAR/TAR documentation dated [DATE], at 1:39 AM revealed a Medication Administration Note that indicated the BiPAP was held due to the resident's oxygen saturation dropping when the BiPAP was on. The documentation noted the resident was currently on six liters of supplemental oxygen via mask. Further review of the clinical documentation revealed no comprehensive respiratory assessments related to the resident's clinical presentation (such as breathing quality, depth of respirations, work of breathing, lung sounds, skin color, or level of consciousness for signs/symptoms of hypoxia/hypercapnia). Closed clinical documentation for Resident CR1 dated [DATE], at 3:15 AM revealed that staff were called to the resident's room at 1:51 AM due to the resident being without spontaneous respirations and had no palpable carotid pulse (a pulsation of blood flow that can be palpated in the neck). CPR 395482 Page 2 of 3 395482 12/27/2024 Nursing and Rehabilitation at the Mansion 1040-52 Market Street Sunbury, PA 17801

F 0580 (cardiopulmonary resuscitation) was initiated by staff. Level of Harm - Minimal harm or potential for actual harm Closed clinical record review for Resident CR1 revealed no documentation that the physician was promptly consulted or notified upon staff assessment of the decreased oxygen saturation, the resident was placed on a higher supplemental oxygen flow rate than ordered by the physician, or the resident had shortness of breath as indicated on the MAR/TAR documentation. Residents Affected - Few The facility failed to immediately consult with Resident CR1's physician regarding a significant change in the resident's physical condition (that is a deterioration in health or clinical complications), and a need to alter treatment significantly (that is, a need to commence a new form of treatment). The above information was reviewed with the Director of Nursing and Employee 1, Assistant Director of Nursing, on [DATE], at 1:45 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395482 Page 3 of 3