Health inspection·April 21, 2023

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews with staff and review of policies and procedures, it was determined that the facility failed to ensure timely access to personal and clinical records for one of seven residents reviewed. (Resident R168) Findings include: The facility policy titled Nursing Services dated March 12, 2023, indicated that the clinical records person or designee was responsible for ensuring that each resident had access to his/her personal records upon request. The policy indicated that each resident would receive confidential treatment of his/or her personal and medical records. The policy stated that the clinical records would be released within 24 hours, after the written consent by the resident or the resident's legal representative was received. The policy also indicated that a copy of the records (in an electronic form or format when such records are maintained electronically) would be provided to the resident or resident's responsible party, within 24 hours of the facility receiving the notice of the request Clinical record review revealed that Resident R168 was admitted to the facility on [DATE] for short term rehabilitation and discharged on July 22 2022. The clinical record for Resident R168 indicated that the responsible party for this resident was his spouse. Clinical record documentation of the closed record for Resident R168 revealed that the spouse of this former resident had requested on December 7, 2022, a personal copy of resident R168's entire medical record. The request was documented, signed and dated by the responsible party for Resident R168. Interview with the Nursing Home Administrator (NHA), on April 19, 2023 at 10:00 a.m. confirmed the responsible party for Resident R168 as his wife. Further during interview with NHA, it was confirmed that the responsible party for Resident R168 was not given electronic access to the personal medical record for Resident R168, within 24 hours of the facility receiving the notice of the request. The NHA reported during this interview that the resident's responsible party did not receive a personal copy of the record for Resident R168 until January 13, 2023; thirty-six days following the signed and dated request from the responsible party. 28 Pa. Code 201.18(b)(3) Management Page 1 of 2 396113 396113 04/21/2023 Health Center at the Hill at Whitemarsh, The 4000 Fox Hound Drive Lafayette Hill, PA 19444

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview with staff, it was determined that the facility did not ensure that proper documentation was maintained in the clinical record related to a resident-initiated discharge to the community that included resident's or resident representative's verbal or written notice of the intent to leave the facility for one of three discharged residents reviewed (Resident R51). Findings include: Review of Resident R51's clinical record revealed that resident was admitted to the facility on [DATE], from a local hospital with diagnoses of Delirium due to physiological condition, Atrial Fibrillation, Retention of Urine, Hypertensive Heart Disease, Obstructive Sleep Apnea, Embolism and Presence of Cardiac Pacemaker and was discharge from the facility back to the community (Independent Living) on March 10, 2023. Further review of Resident R51 clinical record revealed that responsible party was his wife. Review of nursing progress note dated March 10, 2023, revealed that Resident R51 was discharge to Independent Living. Further review of clinical record revealed that there was no documentation regarding the event leading to resident R51's discharge. Further, there was no documented evidence of the resident's responsible party providing facility with a verbal or written notice of their intent to leave the facility. Review of Resident R51's Discharge MDS assessment dated [DATE], Section A 2000 revealed that resident was discharged to the community on March 10, 2023. Further, Section C0500 (BIMS Score) revealed that Resident R51's BIMS score was 4 suggesting that Resident R51 was cognitively impaired. Interview with Social Worker, Employee E4 conducted on April 21, 2023, at 10:26 a.m. revealed that resident was discharge as per wife's request but confirmed that she did not document the verbal notice of discharge from Resident R51's wife. Interview with RNAC (Registered Nurse Assessment Coordinator) Employee E5 conducted on April 21, 2023, at 11:23 a.m. confirmed that there was no documented evidence of the resident's responsible party providing facility with a verbal or written notice of their intent to leave the facility. 28 Pa. Code 201.29(f) Resident's rights 28 Pa. Code 210. 25 Discharge policy 28 Pa. Code 211.5(f) Clinical record 396113 Page 2 of 2