Health inspection·July 14, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation review, review of policy and procedure, and staff interviews, it was determined that the facility displayed past non-compliance by failure to implement appropriate monitoring, supervision, and safety measures to prevent unsafe wandering of a resident (Resident 1) to an unsupervised area of the facility. This failure resulted in harm to the resident who was found unresponsive, had an external body temperature of 106 degrees Fahrenheit (F) and transfer to the hospital where she was intubated (tube inserted into the airway) and placed on a ventilator (a machine that helps someone breathe when they are unable to do so on their own). This failure placed Resident 1 in an Immediate Jeopardy situation. Findings include: Review of facility policy, titled Wandering and Elopements last revised June 2023, indicated that the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the resident. An elopement is defined as when a resident leaves the premises or a safe area without authorization. The policy also states, If a resident is missing, initiate the elopement/missing resident emergency procedure. Review of Resident 1's clinical record on July 14, 2023, revealed diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - disease process that causes decreased ability of the lungs to perform), Bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and history of Traumatic Brain Injury (TBI - injury to the brain caused by a motor vehicle accident in 1987) Review of Resident 1's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated May 18, 2023, revealed the Resident had moderate cognitive impairment. Review of Resident 1's elopement/wandering risk assessment dated [DATE], revealed the Resident was not at risk for elopement, but was coded yes for being cognitively impaired with poor decision-making skills. Review of Resident 1's current care plan revealed a focus area that was initiated February 14, 2023, for cognitive/communication loss related to effects of TBI. Review of information dated July 7, 2023, at 3:30 PM, and submitted by the facility, revealed that Resident 1 was found in her wheelchair in the outdoor courtyard at approximately 3:30 PM by Employee Page 1 of 5 395613 395613 07/14/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 1 (Dietary Staff Member). Employee 1 found Resident 1 unresponsive and slumped over in her wheelchair. The dietary staff member immediately went for help. Resident 1 was immediately pushed in her wheelchair back to her room while cold compresses were being applied. Resident 1's body temperature was 106 degrees F with a non-contact thermometer to the temporal/forehead area. Resident 1 was placed in bed with cold compresses and ice applied to the entire body. Resident 1's vital signs included: blood pressure 95/87 right arm; pulse 160; respirations 24; pulse ox reading was 85% and then increased to 98% when placed on a non-rebreather oxygen mask at 15 Liters per minute of oxygen. The first temperature taken was 106.0 degrees F, the temperature obtained prior to transfer to the hospital was 99.8 degrees. Resident remained unresponsive. The physician was notified about the incident and gave orders to transfer Resident 1 to the hospital for evaluation and treatment. The Resident's Responsible Party was called and a voice message was left several times. Resident 1 was transferred to hospital by EMS on July 7, 2023, at 3:58 PM. Review of hospital records revealed that Resident 1 was admitted with altered mental status and respiratory distress. The Resident was noted to have respiratory acidosis (failure of ventilation resulting in an accumulation of carbon dioxide). The Resident was intubated and placed on a ventilator and transferred to the critical care unit. On July 8, 2023, Resident 1 was extubated (tube and ventilation removed), and on July 9, 2023, the Resident was transferred out of the critical care unit. The outside temperatures on July 7, 2023, for the facility's location, per online historical data, was 87 degrees at 1:53 PM; 89 degrees at 2:53 PM; and 90 degrees at 3:53 PM. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), regarding Resident 1's incident on July 7, 2023, both agreed Resident 1 had the ability to go outside to the courtyard by pushing a handicap button that opens the doors to the courtyard. The door did not alarm if the handicap button was used. The NHA stated that the doors to the courtyards were always locked at night, but open through the day for residents. If exiting the door without using the handicap button, the door would alarm and a code would have to be reset to turn the alarm off. The NHA stated that Resident 1 was observed by a dietary staff person in the courtyard on July 7, 2023, at 1:50 PM, and appeared her usual self. Observation with the NHA on July 14, 2023, of the courtyard where Resident 1 was found on July 7, 2023, revealed that Resident 1 was located at the most distant area from the door, and the area was blocked by overgrown lavender plants. It was obvious that a person would have to physically walk the path in the courtyard to visualize Resident 1. A written statement by day shift Employee 2 (Nurse Aide) dated July 8, 2023, regarding the Resident 1 incident on July 7, 2023, stated, She [Resident 1] ate lunch in the little dining room. Lunch is usually over by 12:30 PM. I did not see her after that. I started rounds at 1:00 PM. I don't normally go look for her because she comes back, or another unit will call. She takes off, all day, every day. She will get nasty if you go after her and tell her she is wet. She normally returns when she is wet. She knows where her room is. I've never seen her go outside before ever. Employee 2 stated she never checked on Resident 1 after seeing her at 12:30 PM, and Employee 2 said she ended her shift at 2:00 PM. A written statement by evening shift Employee 3 (Nurse Aide) dated July 10, 2023, regarding the 395613 Page 2 of 5 395613 07/14/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident 1 incident on July 7, 2023, stated, I've never seen her [Resident 1] outside before, she visits F wing and A wing. Employee 3 also documented that when she initiated rounds that day (2:00 PM), she knew she would have to go and look for her, but decided to do her charting first. Employee 3 never initiated the search for Resident 1 because staff brought Resident 1 onto the unit unresponsive in her wheelchair, after finding her in the courtyard. The NHA and DON were notified of the Immediate Jeopardy on July 14, 2023, at 1:00 PM. An Immediate Action Plan was requested. The facility initiated immediate interventions on July 7, 2023, after the incident. Documents and actions provided by the facility to address the Immediate Jeopardy included: The courtyard doors were switched to lock the automatic door opening function. Residents wanting to go out to the courtyard will need to sign out on the unit, and any cognitively impaired residents will need to be accompanied by a staff or family member. A head count was completed, and current residents were accounted for at that time of the incident. Temperatures were taken on current residents. The Nurse Aide (Employee 2) responsible for this Resident (Resident 1) on the 6:00 AM to 2:00 PM shift was suspended pending the outcome of the investigation. The Nurse Aide (Employee 3) that was assigned to this Resident (Resident 1) on the 2:00 PM to 10:00 PM shift was suspended pending the outcome of the investigation. An investigation was initiated to interview employees in the facility on July 7, 2023; Administrator/Designee continue to obtain staff statements. A risk management report was completed on July 7, 2023; the Medical Director was updated on the incident and the Resident's condition; on the Resident's return, the care plan will be reviewed and updated as needed. Additionally, an ad hoc QAA committee meeting was held to review the investigation process and develop additional recommendations on July 7, 2023. An audit was completed of current residents that are triggered for locomotion off unit to ensure care plan intervention for observation. The facility will continue to audit current residents that trigger for locomotion off unit to ensure care plan intervention for observations weekly for two months, then monthly for two months. Will review outcomes at QAPI (Quality Assurance Performance Improvement) meetings with interdisciplinary teams. The facility's Immediate Action Plan was reviewed on July 14, 2023, during the onsite survey. Facility staff were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge that the following steps were taken: 1) 395613 Page 3 of 5 395613 07/14/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0689 Residents with cognitive impairment that wander throughout the facility had their care plans reviewed and Level of Harm - Immediate jeopardy to resident health or safety updated, if needed, to ensure adequate supervision Residents Affected - Few Education was initiated on July 7, 2023, with the facility staff on the Federal Regulation citation F 689 Free 2) of Accident Hazards/Supervision/Devices 3) Education was initiated on July 7, 2023, with the facility staff on courtyard guidelines 4) Education was initiated on July 7, 2023, with the staff on the facility policy for Wandering and Elopements 5) Newly admitted residents that wander throughout the facility continue to be evaluated for safety and elopement risks during the admission observation and with a change in condition 6) Courtyard doors addressed so they are immediately alarming when opened until responded to by staff The facility's Immediate Action Plan was reviewed on July 14, 2023, which included audits and education. Observations were made of the courtyard and the exit door to ensure safety measures were in place and facility staff were interviewed to confirm understanding of education. Prior to the onsite investigation, the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent unsafe wandering of Resident 1 to an unsupervised area of the facility. This failure resulted in harm to Resident 1, who was found unresponsive in the courtyard on a 90 degree day, had an external body temperature of 106 degrees Fahrenheit (F) and transfer to the hospital for a five day stay which included mechanical ventilation. The Immediate Jeopardy was lifted on July 14, 2023, at 3:03 PM, and the deficient practice was found to be past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3)(e)(1) Management 395613 Page 4 of 5 395613 07/14/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0689 28 Pa. Code 211.10(a)(d) Resident care policies Level of Harm - Immediate jeopardy to resident health or safety 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Residents Affected - Few 395613 Page 5 of 5