Health inspection·September 26, 2023

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 observations, review of clinical records, facility policies and facility documentation, and staff and resident interviews, it was determined that the facility failed to provide adequate supervision that resulted in actual harm including a laceration requiring seven sutures (stitches to close a wound), head injury, and skin tear of forearm, to one of two residents reviewed (Resident R1). Findings include: Review of the facility policy entitled, Comprehensive Care Plan dated 3/13/23, revealed that the care plan will describe at a minimum, the following: (a) the services that are to be furnished to attain or maintain the Resident's highest practical physical, mental and psychosocial well being . 6. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the facility policy entitled, Fall Prevention Program dated 3/13/23, revealed that residents that have a fall history will be placed on the fall prevention precautions, .6. fall risk interventions will at a minimum: include educating staff, resident, and family to increase the awareness of residents risk for falling and possible interventions to minimize the risk .8. Certified Nursing Assistants may assist with fall prevention as follows: 9a) follow the interventions as outlined on the care plan and [NAME] [system for resident care information to be relayed to staff] . Review of Resident R1's clinical record revealed an original admission date of 12/14/2017, with diagnoses that included heart failure, weakness of the right side of the body following a stroke, diabetes, difficulty walking, obesity, low back pain, legal blindness, Alzheimer's disease and dementia (condition characterized by progressive, persistent severe impairment of intellectual capacity, including memory loss and confusion). Review of the physician order sheet, dated 9/26/23, revealed that on 1/03/23 an order was written Do Not leave unattended in bathroom. Review of a care plan entitled I am at high risk for falls care plan, revealed don't leave me unattended in the bathroom and was created on 1/03/23. Review of nursing documentation, dated 9/11/23, written by Registered Nurse (RN) Employee E1, stated that Resident R1 experienced leaning back on the toilet for about 20 seconds with some tremors but was still alert and talking. Page 1 of 3 395793 395793 09/26/2023 Orchard Manor 20 Orchard Drive Grove City, PA 16127

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of nursing documentation dated 9/14/23, written by RN Employee E2 stated called to hallway due to resident going unresponsive when staff stood Resident R1 up. Resident was unresponsive for approximately three minutes. Upon arrival resident was alert and oriented but unaware of recent incident .Staff reported these episodes usually happened when resident is straining during bowel movement and occasionally when urinating . Review of nursing documentation dated 9/15/23, written by Licensed Practical Nurse (LPN) Employee E3 revealed that he/she was called to the shower room by the Nurse Aide (NA) as Resident R1 had an unresponsive episode while getting on toilet lasting five seconds . Review of nursing documentation dated 9/15/23, written by RN Employee E4 stated the RN was requested to go to Resident R1's room at approximately 4:00 p.m. Resident R1 was found lying on his back in his bedroom in a pool of blood. Resident R1 was noted as having a laceration above his right elbow, an abraded area on his right arm and in between the pinkie and ring finger of the right hand. Notifications were made and resident was sent to hospital. Review of nursing documentation dated 9/15/23, stated the LPN E3 was called to the Resident R1's bathroom. Resident R1 was on the floor in his bathroom on right side, head against door frame, blood on floor. Resident R1 was alert, talking, complained of some discomfort to right eyebrow, no other complaint of pain. Laceration noted to the right eyebrow, skin tear to left forearm and left hand. Wound to head covered with gauze and wrapped with kling Xeroform applied to left arm and wrapped, steri strips to skin tear between finger of left hand. Review of facility incident report and NA Employee E5's statement revealed that Resident R1 was assisted to the bathroom by two staff. NA Employee E5 was with the resident and the second NA left the room. NA Employee E5 left the resident alone in the bathroom to retrieve a brief (incontinence product) for Resident R1. When NA Employee E5 returned, Resident R1 had fallen off the toilet in the bathroom. Observation on 9/26/23, of the location of the briefs revealed that their storage area was approximately 30 plus feet from Resident R1's door. NA Employees E6 and E7 confirmed that the briefs were kept at the location observed which was on the right side of the shower room. Review of hospital records revealed the final diagnoses from Resident R1's admission to the hospital was fall, eye brow laceration requiring seven sutures, head injury, skin tear of forearm without complication and contusion. Observation of Resident R1 on 9/26/23, at 10:15 a.m. noted, healing area from eye brow laceration with discoloring of yellow, purple and black colors with slight swelling still apparent. Left forearm wrapped, small bruised areas noted on both arms and large dark red purple area on the right arm from the elbow to shoulder area. Resident R1 stated at the time of the observation I took a tumble out the door. During an interview on 9/26/23, at 3:24 p.m. the Director of Nursing confirmed that Resident R1 should not have been left unsupervised in the bathroom. The facility failed to provide adequate supervision that resulted in actual harm to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee 395793 Page 2 of 3 395793 09/26/2023 Orchard Manor 20 Orchard Drive Grove City, PA 16127

F 0689 28 Pa. Code 201.18(b)(1) Management Level of Harm - Actual harm 28 Pa. Code 201.18(b)(3)(e)(1) Management Residents Affected - Few 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395793 Page 3 of 3