Health inspection·July 5, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on policy review, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards for one of three residents reviewed (Resident 3). Residents Affected - Few Findings include: Review of facility policy, titled Accidents and Incidents - Investigating and Reporting last revised July 2017, revealed that the policy stated, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Review of policy section, titled Policy Interpretation and Implementation revealed subsections included, 1. The nurse supervisor/charge nurse and/or the department director of supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; .k. Any corrective action taken .l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. Subsection 5 of the aforementioned policy stated, The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. Review of Resident 3's clinical record on July 3, 2023, at approximately 10:00 AM, revealed diagnoses including dementia (irreversible, progressive degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living) and atrial fibrillation (irregular heart rhythm). Review of Resident 3's nursing progress note by Employee 1, entered on May 11, 2023, at 8:53 AM, stated, Nurse called into resident's room Resident presented with old [Right Lower Extremity] laceration that was bleeding through dressing and onto bed, blood in clotting formation, significant amounts of blood on bed. Site cleansed with soap /water and steri-strips applied and pressure dressing applied. MD [provider] and family notified. Review of Resident 3's clinical record revealed no injury or laceration to Resident 3's right lower Page 1 of 2 395844 395844 07/05/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0658 extremity prior to May 11, 2023, at 8:53 AM. Level of Harm - Minimal harm or potential for actual harm Further review of Resident 3's clinical record revealed a document, titled eINTERACT Change in Condition Evaluation V5 - Rev 2.0 completed by Employee 1 with an Effective Date of May 11, 2023. In the evaluation, Employee 1 documented that Resident 3 suffered a Skin wound or ulcer to the Right lower leg (front) on May 10, 2023, during the night. Further, it was documented that the attending physician was notified on May 10, 2023, at 6:00 PM. Review of the document revealed it did not contain elements listed in the facility's Accidents and Incidents - Investigating and Reporting. Further, the document revealed no documented observed wound characteristics, such as length, width, depth of the wound, nor general condition of the wound. Residents Affected - Few Review of Resident 3's interdisciplinary progress notes revealed no documentation of the incident by any staff on the evening of May 10, 2023. During a staff interview on July 3, 2023, at approximately 11:00 AM, Director of Nursing (DON) revealed the facility did not have an incident report regarding the injury to Resident 3's right leg. During a staff interview on July 5, 2023, at approximately 2:40 PM, DON revealed that it was the facility's expectation that the Registered Nurse Supervisor would have initiated an incident investigation report at the time of the injury. 28 Pa code 211.12(d)(1)(3)(5) Nursing services 395844 Page 2 of 2