Health inspection·July 24, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed Residents Affected - Some to ensure that clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). This deficiency was cited as past noncompliance. Findings include: The facility's policy regarding condom catheters (a urine collection device that fits like a condom over the penis, but also has a tube that goes to a collection bag strapped to the leg), dated August 14, 2023, indicated that condom catheters will be changed daily and as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 8, 2024, revealed that the resident was understood, could understand others, had an external catheter, had diagnoses that included Multiple Sclerosis (a chronic disease of the central nervous system), and quadriplegia (a condition where all four limbs experience paralysis). A care plan for the resident, dated April 3, 2024, revealed that the resident required an external catheter related to a neuromuscular dysfunction (affecting the function of muscles due to problems with the nerves and muscles in the body) of his bladder. Staff were to change his condom catheter per the physician's order and as needed. Physician's orders for Resident 1, dated May 1, 2024, included an order for condom catheter care. Staff were to provide catheter and peri-care (washing the genitals and anal area) that included cleansing around the catheter and the perineal site with soap and water as needed every shift, and staff were to record the urinary output amount every shift. A nursing note for Resident 1, dated April 1, 2024, revealed that the resident arrived at the facility with his wife and daughter via electric wheelchair, and his wife was steering the electric wheelchair due to resident not being able to use his hands. The resident was alert and oriented and had a condom catheter. A nursing note for Resident 1, dated July 15, 2024, revealed that the resident was readmitted to the facility from the hospital. The resident's wife was requesting that his condom catheter be replaced daily (she provided them) and the order was updated. Page 1 of 2 395726 395726 07/24/2024 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 1's Medication Administration Records (MARs), dated April, May, June, and July 2024, revealed that there was no documented evidence that the resident's condom catheter was being changed daily as per the facility's policy until July 15, 2024, when a physician's order was obtained for staff to change the resident's condom catheter daily per the family request. Interview with Resident 1 on July 24, 2024, at 11:15 a.m. revealed that staff have been changing his condom catheter daily. Interview with the Nursing Home Administrator on July 24, 2024, at 4:32 p.m. revealed that when Resident 1's wife requested that his condom catheter be changed daily, they realized that the resident did not have a specific physician's order to change the resident's condom catheter daily. She indicated that staff interviews conducted during their investigation revealed that they were changing the condom catheter when they were doing the resident's cath care. She indicated that they caught it and obtained orders. Following Resident 1's wife request on July 15, 2024, the facility's corrective actions included: Interviews were conducted with staff to see if the condom catheter was being changed daily. A physician's order was obtained to change Resident 1's condom catheter daily, so it would be documented on the MARs. An audit was performed to see if any other residents had a condom catheter. Education was provided to licensed nursing staff on following/signing off orders and changing condom catheters per the facility's policy. Audits will be performed three days per week for four weeks, then monthly for two months. The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F842 on July 17, 2024. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395726 Page 2 of 2