Health inspection·January 24, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, select resident incident report, and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to thoroughly conduct and document the results of a professional nursing assessment regarding the clinical status of a resident following a change in condition for one resident (Resident 1) out of 8 residents reviewed. Residents Affected - Few Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient ' s EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: · Assessments · Clinical problems · Communications with other health care professionals regarding the patient · Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of Resident 1's clinical record revealed an admission date to the facility December 5, 2018, with diagnoses to include aphasia (a language disorder that affects the ability to speak and understand what others say. It usually happens suddenly after a stroke or traumatic brain injury). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated November 7, 2024, revealed that Resident 1 was cognitively impaired and required substantial assistance with activities of daily living. A review of nursing documentation dated September 10, 2024, at 7:38 p.m., revealed Resident 1's daughter expressed concern about her mother's condition to Employee 1 (LPN). Employee 1 noted the resident was clammy, and lethargic. Resident 1's vital signs were taken and her Oxygen saturation (the amount of oxygen you have circulating in your blood) was 87%. The normal range is 95 to 100%. Resident Page 1 of 2 395567 395567 01/24/2025 Dunmore Health Care Center 1000 Mill Street Dunmore, PA 18512

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1's daughter asked the RN supervisor on duty Employee 2, to assess her mother. The resident's nursing progress note stated that Employee 2 was present on unit to assess the resident. However, there was no documented evidence that an assessment was completed. Further review of the clinical record revealed no additional documentation regarding Resident 1's condition until September 11, 2024, at 9:10 a.m., when Employee 3 (RN) noted the resident's condition had not improved and contacted the physician. STAT (immediate) labs were ordered, and results returned at 11:53 a.m. indicated an elevated white blood cell count of 32.68 K/ul (thousands per microliter of blood normal adult 4.0 K/ul -11.0 K/ul or 4000-11000 cells per microliter), consistent with an active infection. However, the resident was not transferred to the hospital until 2:01 p.m. on September 11, 2024. Resident 1 was later diagnosed and treated for sepsis (a condition that arises when the body's response to infection causes injury to its own tissues and organs) returning to the facility on September 17, 2024. There was no documented evidence that a thorough and timely nursing assessment was conducted following the resident's initial change in condition. Additionally, the facility failed to escalate care in a timely manner, which delayed appropriate medical intervention. The facility failed to ensure nursing services were provided consistent with professional standards. Interview with the Nursing Home Administrator and Director of Nursing on January 24, 2025, at 11:30 a.m. confirmed that the facility nursing staff didn't timely assess and timely send the resident to the hospital for her documented change in condition resulting in the lack of provided nursing services consistent with professional standards 28 Pa Code 211.12 (1)(3)(5) Nursing Services 395567 Page 2 of 2