Health inspection·August 15, 2024

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 reviews of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to implement effective safety measures by not supervising use of a cold pack in a manner that promotes safety for one of three residents reviewed (Resident R1), which resulted in actual harm of a superficial frostbite burn (involving the epidermis and dermis layers of the skin that is red blistered swollen and painful). This was identified as harm for one resident (Resident R1). Findings include: A review of the facility policy, Ice/Cold Pack, last reviewed 1/18/24, indicated the facility will provide appropriate toweling between ice pack and area to be treated. The treatment time is 10-20 minutes and should be checked every 10 minutes. The treatment and response to treatment should be documented in medical record. A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included sciatica (pain along sciatic nerve), hyperlipidemia (high levels of fat particle in the blood), polyneuropathy (multiple peripheral nerves become damaged causing pain) and hypertension (blood against the artery walls is too high). Further review indicated the resident had a Brief Interview of Mental Status of 15 which indicated Resident R1 was cognitively intact. Resident R1 was discharged home on 8/11/24. A review of the Physical Therapy (PT) Evaluation & Plan of Treatment dated 7/29/24, indicated that Resident R1 treatment approaches may include a modality (method of treatment, piece of equipment, or Medical Director. A review of the care plan initiated 7/27/24 for potential for pain related to impaired mobility, failed to include the use of cold packs as an intervention. A review of an incident report dated 7/30/24, indicated Resident R1 stated ice pack was left on direct skin for too long. Redness and blistering were noted behind the right knee. Injury type observed at the time of the incident was a burn to the right inner knee area. Physician and daughter were notified. A review of a physical therapy treatment encounter note dated 7/30/24, indicated Resident R1 was given ice pack by PT initially and declined all other PT services the rest of the day. Page 1 of 3 395851 395851 08/15/2024 Rehab & Nursing Ctr Greater Pittsburgh 890 Weatherwood Lane Greensburg, PA 15601

F 0689 Level of Harm - Actual harm A review of a wound and vascular progress note dated 8/6/24, indicated Resident R1 admitted to removing cloth from ice pack and placing ice pack directly on her skin. Behind the right knee was noted to have redness and blistering. Encounter diagnosis of superficial frostbite of right knee and lower leg noted. Residents Affected - Few A review of a facility witness statements dated 8/8/24, indicated the following: PT Employee E1 indicated Resident R1 was approached for treatment which she refused due to pain. PT Employee E1 spoke with nurse on the unit regarding pain medication, which were not due at the time. Ice pack was then offered to Resident R1. Nurse confirmed I [PT employee E1] provided with proper toweling. Licensed Practical Nurse (LPN) Employee E2 indicated At no time did I [LPN Employee E2] give an ice pack to anyone on the 200 unit. During an interview on 8/14/24 at 11:58 a.m., PT Employee E1 revealed I went to see Resident R1 sometime before lunch however treatment was refused due to pain. Resident wanted pain medication and ice, so I spoke with the nurse to see if pain medication was due, but it was not. I went to get the ice from the freezer for the nurse and verified with her that ice pack was covered and being given to resident at that time. I went back to attempt treatment a couple hours later, but resident refused again. During an interview on 8/15/24 at 9:42 a.m., with Licensed Practical Nurse (LPN) Employee E2, revealed they were the nurse caring for Resident R1 on the day of the incident. LPN Employee E2 stated I was never shown an ice pack that day. I never saw the resident with an ice pack. I did not provide resident with direct contact care the second half of my shift to notice any burn. Phone calls were placed to Resident R1 on 8/14/24 and 8/15/24, voice mails were left and telephone calls were not returned. The facility provided documentation of the in-service training that was provided to the staff, including Registered Nurses, Licensed Practical Nurses, Occupational Therapist and Physical Therapist, at the facility on 8/6/24, which addressed following the facility policy and procedures for using ice/cold packs. During interviews with nursing staff on 8/15/24 from 9:42 a.m. through 10:34 a.m. revealed LPN Employee E2, Registered Nurse (RN) Supervisor Employee E3, LPN Employee E4, Unit Clerk Employee E5, LPN Employee E6, LPN Employee E7, LPN Employee E8, and LPN Employee E9 confirmed proper procedure for using ice/cold packs. During an interview on 8/15/24, at 11:18 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to implement effective safety measures by not providing education and supervision of the use of an ice pack resulting in actual harm of a frostbite burn to Resident R1. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1) Management. 395851 Page 2 of 3 395851 08/15/2024 Rehab & Nursing Ctr Greater Pittsburgh 890 Weatherwood Lane Greensburg, PA 15601

F 0689 28 Pa Code: 211.10 (c)(d) Resident care policies. Level of Harm - Actual harm 28 Pa Code: 211.11 Resident care plan. Residents Affected - Few 395851 Page 3 of 3