Health inspection·May 29, 2025

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 review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. Findings include: Review of the facility policy Accident Prevention, dated 1/6/25, indicated it is the facility's policy to prevent resident accidents and injuries. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/15/25 included diagnoses of chronic obstructive pulmonary disease (COPD - a group of progressive lung disorders characterized by increasing breathlessness) and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of Section GG: Functional Abilities indicated that Resident R1 required partial/moderate assistance for chair/bed-to-chair transfers. Review of a physician order dated 9/13/24 indicated Resident R1 required an assist of one staff member and the use of a rolling walker. Review of Resident R1's plan of care for ADLs (activities of daily living) Functional Status / Rehabilitation Potential, dated 2/5/25, indicated that the resident will have all necessary assistance with ADLs. Review of an on-call physician note dated 5/3/25 at 10:15 a.m. indicated, Patient sustained a deep laceration to right lower leg from [his/her] wheelchair. Patient with profuse bleed and subsequently transferred to Emergency department for evaluation. Review of a progress note dated 5/3/25 at 10:22 a.m. indicated, Called to pt (patient) room by nurse on unit. During stand to pivot transfer leg caught on wheelchair causing laceration to right lower extremity. Approx 7 centimeters (cm) x 1 cm. Moderate bleeding noted. Pressure dressing applied to control bleeding. [On-call provider] contacted and pt sent to hospital for eval. Review of hospital documentation, dated 5/3/25, indicated, [Resident R1] presents to the emergency room from [facility] sent for laceration right lower extremity. Apparently patient sustained a Page 1 of 4 395640 395640 05/29/2025 John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132

F 0689 Level of Harm - Actual harm laceration to [his/her] right lower extremity on the leg of [his/her] wheelchair. An addendum dated 5/3/25 at 5:45 p.m. indicated that while waiting for transportation to return to the facility, Resident R1 appeared to bleed through the dressing. Sutures, surgifoam (dressing or powder used to control bleeding), and dressing applied to the wound. Residents Affected - Few Review of a progress note dated 5/3/25 at 5:47 p.m. indicated Resident R1 returned from the hospital with 11 staples and 2 sutures per report from ER nurse, states that resident has had excessive bleeding at hospital and the 2 sutures were added as the resident was being d/c (discharged ) from the hospital due to the excessive bleeding, nurse advised pressure dressing was put on and 2 rounds of quick clot (gauze or granules that promote blood clotting). Review of a progress note dated 5/3/25 at 8:42 p.m. indicated Resident R1's pressure dressing from the hospital had bled through, and the wound was redressed with a pressure dressing and applied ABD (highly absorbent dressing that provides padding and protection for large wounds), Kerlix (absorbent rolled bandage), ace (elastic bandage). Review of a progress note dated 5/4/25 at 4:22 a.m. indicated Resident R1's wound continued to ooze. Review of a progress note dated 5/4/25 at 7:40 a.m. indicated, Notified by nurse on unit that blood saturating through the pressure dressing to the right lower extremity. Dressing removed with nurses on unit present to eval (evaluate). Dressing was from knee to ankle, moderate to gross amount of blood noted on dressing. Upon removal clot noted to area approx. 4 cm round with a 1 cm wide tail approx. 6-7 cm. Staples intact. 2-3 sutures noted at top of area where blood continued to ooze steadily. Pressure applied with folded 4x4 (four-inch square gauze) but blood continued to penetrate through. Review of a provider note dated 5/4/25, at 7:43 a.m. indicated, to send Resident R1 to the emergency department for further evaluation. Review of a progress note dated 5/4/25, at 1:18 p.m. indicated the hospital called and stated two additional staples were inserted and quick clot administered. Review of hospital documentation dated 5/4/25, indicated, [Resident R1] was brought into the emergency room due to bleeding at the laceration site which was repaired yesterday. Patient apparently sustained a contusion and laceration of the right leg when she hit her wheelchair yesterday and the laceration was repaired with staple and stitches. Dressing was applied but apparently kept bleeding this morning hence was sent to the emergency room for evaluation. Documentation further stated that two additional staples were used to control the bleeding site and quick clot dressing was applied. Review of facility submitted information on 5/6/25, indicated on 5/3/25, At approximately 10:00 AM alert x 1 resident [Resident R1] sustained a laceration to the right lower extremity during transfer from bed to wheelchair. During transfer with CNA (Nurse Aide) resident became weak and buckled at the knees. CNA braced resident to prevent fall and placed [him/her] in the w/c (wheelchair). When resident was safely in w/c CNA noticed blood from his/her] right leg. CNA applied pressure to the area and called out for help. LPN (licensed practical nurse) responded immediately and assessed wound. Supervisors notified and assessed resident. Area cleansed with normal saline and pressure dressing applied. Call placed to [medical providers] ordered resident sent to hospital for evaluation. Emergency contact notified. 395640 Page 2 of 4 395640 05/29/2025 John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132

F 0689 Level of Harm - Actual harm Review of an update to the facility submitted information dated 5/14/25, indicated, It is believed that the w/c leg rest hinge bracket caused the laceration. No sharp edges noted. OT (occupational therapy) padded both sides of w/c. Resident transfer was assist x 1 with wheeled walker at time of incident. Transfer changed to assist x 2 with rolling walker per OT. Residents Affected - Few Review of an employee statement written by NA, Employee E1, dated 5/3/25 indicated, I was transferring [Resident R1] from the bed to the w/c. When [he/she] stood up and began to pivot into w/c [he/she] stated [he/she] was going to fall, I assisted in the pivot to w/c. When [he/she] was in the w/c safely I noticed blood on the floor. I applied pressure with my hands and called out to the HK (housekeeper) to grab the nurse. They came in dressed area and I assisted with vitals. We got [him/her] back into bed and comfortable. Review of the facility's plan of correction included: -Wound will be monitored for signs/symptoms of infection. -Nursing care plan updated to include any new orders. -Interventions are put into place to prevent injuries or reduce the risk of injuries for individual resident needs. -PT/OT (physical therapy / occupational therapy) consult ordered for transfers. -Wheelchair removed from service to be inspected for sharp edges. -All residents are assessed on admission, quarterly and upon incident for appropriate care plan adjustments. -All incidents and accidents are tracked and trended by the quality assurance committee and reviewed for recommendations to prevent injuries. Review of education provided by the physical therapy department specific to Resident R1's transfer needs was provided to staff on 5/12/25. Review of facility provided education information and on-going quality assurance measures revealed facility staff received education on accident prevention, falls, and reviewing ADL information in the computerized charting system, as well as ongoing monitors to prevent future accidents and improve systems. This education was completed on 5/23/25. During an interview on 5/28/25 at approximately 3:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 395640 Page 3 of 4 395640 05/29/2025 John J Kane Regional Center-MC 100 Ninth Street McKeesport, PA 15132

F 0689 28 Pa. Code 211.10(c)(d) Resident care policies. Level of Harm - Actual harm 28 Pa Code 211.12(d)(1)(2)(5) Nursing services. Residents Affected - Few 395640 Page 4 of 4