Health inspection·May 15, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select facility investigative reports and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for three of seven sampled residents (Resident 1, 2, and 3). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records. A review of clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include Parkinson's disease (brain disorder that causes unintended or uncontrollable movements). A review of the resident's April 2023 Medication Administration Record (MAR) revealed that on April 16, 2023, Employee 1, RN, (Registered Nurse), who was working in the capacity as the Director of Nursing at that time, signed the record indicating that she removed the resident's bilateral lower extremity tubi grips (a compression bandage) for the evening shift. Employee 1 documented on April 20, 2023, and April 26, 2023, that she administered Tylenol 325 mg two tablets, Sinemet 25-100MG one tablet, and Miralax 17 GM dissolved in eight ounces of liquid at 2:00 PM to Resident 1. A review of a facility investigation revealed, however, that Employee 1 was not working at the time Page 1 of 2 395824 395824 05/15/2023 Emmanuel Center for Nursing 600 School House Road Danville, PA 17821

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she documented the removal of Resident 1's tubi grips. Employee 1 was not working as the medication nurse on April 20, 2023,and April 26, 2023 and the facility determined that Employee 1 documented medications and treatments that she did not administer or provide to the resident. A review of clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses to include dementia (the loss of cognitive functioning, thinking, remembering, and reasoning). A review of the resident's April 2023 MAR revealed that on April 16, 2023, Employee 1 documented that she administered the resident's Aspercreme lotion to the left hand, knees, and hips at 8:00 PM and administered Gabapentin 100 mg one capsule at 10:00 PM. On April 26, 2023, Employee 1 documented that she administered Gabapentin 100 mg one capsule and provided a Mighty Shake at 2:00 PM to Resident 2. A review of a facility investigation revealed that Employee 1 was not working at the time she documented that she administered the Aspercreme and Gabapentin to Resident 2 on April 16, 2023. Employee 1 was not working as the medication nurse on April 26, 2023, when she documented that she administered the 2:00 PM Gabapentin and provided the Mighty Shake. The facility determined that Employee 1 documented that medications that she did not administer and provided a nutritional supplement and treatment to the resident, which she did not actually provide. A review of clinical record revealed Resident 3 was admitted to the facility on [DATE], with diagnoses to include Type II Diabetes and atrial fibrillation(an irregular and often very rapid heart rhythm). A review of the resident's April 2023 MAR revealed on April 16, 2023, Employee 1 documented that she administered the resident's 8:00 PM Gabapentin 800 mg, one tablet, Metoprolol Tartrate 100MG one tablet, Senna Plus 50-8.6 MG two capsules, Refresh eye drops one drop in each eye, Lantus 10 units, Melatonin 3 MG two tablets, Myrbetriq 25MG two tablets, and Coumadin 3 MG one tablet. A review of a facility investigation revealed Employee 1 was not working at the time she documented that she administered the resident's medications on April 16, 2023, at 8:00 PM. The facility determined that Employee 1 documented medications that she did not administer to the resident. An interview with the Nursing Home Administrator on May 15, 2023, at approximately 2:00 PM confirmed that Employee 1, RN, failed to accurately document in the residents' clinical records. 28 Pa. Code 211.5 (f)(h) Clinical records. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services. 395824 Page 2 of 2