Health inspection·July 30, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to timely notify hospice of a change in condition for one of six residents reviewed (Resident 1). Residents Affected - Few Findings Include: Review of facility policy, titled Notification of Changes, revised August 29, 2023, revealed, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. Review of the facility's hospice contract with Resident 1's hospice provider, most recently dated August 26, 2013, revealed Facility shall immediately notify Hospice when: a. A significant change in a patient's physical, mental, social or emotional status occurs. b. Clinical complications appear that suggest the need to alter the plan of care. The contract also stated, in part, to ensure that the needs of the patient are addressed and met 24 hours per day. Review of Resident 1's clinical record revealed diagnoses that included acute respiratory failure with hypoxia (when the lungs can't get enough oxygen into the blood) and diffuse large B-cell lymphoma (a type of cancer). Further review of Resident 1's clinical record revealed that she was admitted to hospice on July 11, 2024, with a primary diagnosis of interstitial pulmonary disease (an umbrella term used for a large group of diseases that cause scarring of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe and get oxygen to the bloodstream). Review of Resident 1's physician orders revealed an order dated June 27, 2024, for oxygen at 5 L (liters) via nasal cannula. Review of Resident 1's nursing progress note dated July 21, 2024, at 11:43 PM, revealed that at around 9:00 PM, Resident 1's oxygen saturation was 86% on 5 L of oxygen via nasal cannula. RN (registered nurse) assessment revealed the Resident was laying in her bed with her eyes closed, with oxygen saturation 48% on 5 L of oxygen. Resident 1 denied shortness of breath, pain, or discomfort. Resident 1 received as needed morphine for comfort. Review of Resident 1's Medication Administration Record (MAR) dated July 2024, revealed that Page 1 of 2 395784 395784 07/30/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0580 Resident 1 received as needed morphine on the following dates and times, and with the following oxygen saturations documented during those times: Level of Harm - Minimal harm or potential for actual harm July 21 at 9:07 PM- oxygen saturation 86% Residents Affected - Few July 22 at 12:32 AM- oxygen saturation 48% July 22 at 5:58 AM- oxygen saturation 52% July 22 at 8:35 AM- oxygen saturation 44%. Review of Resident 1's nursing progress note dated July 22, 2024, at 9:06 AM, revealed the nurse was called into the Resident's room related to a change in condition. Resident was resting in bed, oxygen saturation 89% on supplemental oxygen, no signs or symptoms of respiratory distress. The note further stated that one of Resident 1's representatives was at the bedside and that hospice was contacted at the request of another one of Resident 1's representatives. Review of Resident 1's hospice progress note dated July 22, 2024, revealed that Resident 1 was seen by hospice on this date and her oxygen saturation was now 96% on 5 L. During an interview with the Director of Nursing and Employee 1 (RN) on July 29, 2024, at 11:20 AM, they stated that with Resident 1 being on hospice and having low oxygen saturations, it could have been an indication that Resident 1 was starting to decline and transition. In a follow-up interview with the Nursing Home Administrator on July 30, 2024, at 11:22 AM, she stated that hospice should have been contacted during the night when Resident 1's oxygen saturation was 48-52%. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395784 Page 2 of 2