Health inspection·July 24, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 facility policy, review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from an accident of a roll out of bed for one of three residents (Resident R1). Findings include: Review of the facility policy Accidents/ Incidents last reviewed on 6/26/24, with a previous review date of 10/4/23, indicated that the Center will report, review and investigate all accidents/incidents which occur. Any accident/incident that may be considered an allegation of abuse/neglect, etc. will be managed in accordance to the Abuse Prohibition Policy. An accident is defined as an unexpected incident that may result in injury. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included severe unspecified dementia without behavioral disturbance, bacteremia, sepsis, a stroke, speech and language deficits and other brain infarcts. A Minimum Data Set (MDS - periodic assessment of a resident's abilities and care needs) dated 7/7/24, indicated the diagnoses remained current. Section GG of the MDS also indicated that Resident R1 was dependent for rolling left to right. Dependent on staff (meaning that the helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity). Review of Resident R1's plan of care for ADL Self Care Performance Deficit related to Dementia active on 7/3/24, failed to include in the interventions what level of staff assistance Resident R2 required for transferring to bed from her wheelchair and for dressing/undressing. The care plan was not updated to reflect the physician's order for transfer and assistance. Review of the facility provided documentation dated 7/8/24, indicated Licensed Practical Nurse(LPN) Employee E1 turned Resident R1 onto her side towards her, then left her to go into the hall to look for Registered Nurse(RN) Employee E2 who was bringing in wound care supplies, leaving Resident R1 on her side and unassisted and Resident R1 rolled onto the floor. Review of a written statement by LPN Employee E1 dated 7/8/24, indicated, I was doing last rounds, RN Employee E2 came into the room and was going to do Resident R1's coccyx treatment. I had positioned Resident R1 on her left side towards me. I was waiting for RN Employee E2 to return and I stepped away from the bed and looked back to see Resident R1 sliding off the bed. I hurried back to attempt to catch her but she rolled out of bed. Page 1 of 2 395783 395783 07/24/2024 Peters Township Post Acute 113 West McMurray Road McMurray, PA 15317

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a written statement by RN Employee E2 dated 7/8/24, indicated, Resident R1 was on her left side when I exited the room to gather supplies for her wound care. When I re- entered the room, LPN Employee E1 was standing in the doorway and I walked in to find Resident R1 had rolled off the bed striking her head on the night stand. During an interview on 7/24/24, at 10:08 a.m., LPN Employee E3 stated that she is agency but would look on her chart. I asked if she had access to the computer, she indicated she did and after prompting, stated oh yea, the kardex. During an interview on 7/24/24, at 10:11 a.m., 6/2/24, at 3:34 p.m. NA Employee E4 stated she reviews the the resident's kardex for residents bed mobility and transfer status in the computer, that everyone has access. During an interview on 7/24/24, at 10:15 a.m., RN Employee E5 stated that there are cheat sheets for the Nurse Aides she would look at, then the residents kardex in the computer for their transfer status. During an interview on 7/24/24, at approximately 11:30 a.m. the Director of Nursing stated that the LPN walked away for Resident R1's bed to go into hall to look for the RN leaving the resident on her side. During an interview on 7/24/24, at approximately 12:10 p.m., the Nursing Home Administrator, Director of Nursing and Assistant Director of Nursing confirmed that facility failed to protect Resident R1 from an accident that involved a roll out of bed. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services. 395783 Page 2 of 2