Every finding on record at Beaumont at Bryn Mawr

Based on observation, review of facility policy, and staff interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards for two of 12 residents reviewed. (Resident R1 and Resident R15) Findings Include: Review of facility policy titled, Administering Oral Medications dated October 2010 states, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Under Step in the Procedure the policy states, .16. Allow the resident to swallow oral tablets or capsules at his or her comfortable pace .21. Remain with the resident until all medications have been taken. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE] with the diagnoses of: Gout, Insomnia, Dementia, progressive generative disease of the brain) and Osteoarthritis (degenerative joint disease). Review of Resident R1's Minimum Data Set (MDS- assessment of resident's needs) completed on June 11, 2024 revealed a Brief Interview with Mental Status (BIMS) score of 5, which indicated that the resident had cognitive impairment. Observation of Resident R1 on August 12, 2024 at 10:14 a.m. revealed the resident was at the bedside in her wheelchair with a tray table in front of her eating her breakfast. Observation of Resident R1's tray table revealed the resident had a clear medicine cup with four pills. Interview held with private duty nurse aide, Employee E10 at 10:15 a.m. reports the resident's medication bedside were vitamins and Tylenol. Employee E10 stated the nurse left them there for the resident to take. Interview with Licensed nurse, Employee E4 on August 12, 2024 at 10:31 a.m. revealed the license nurse did dispense the medication this morning while the resident was in the bathroom. Licensed nurse, Employee E4 reported that she does not typically leave medications bedside, and that the medications in the cup were vitamins. Review of Resident R15's clinical record revealed the resident was admitted to the facility March 28, 2024 with diagnoses of Congestive Heart Failure (excessive fluid caused by a weakened heart muscle), Atrial Fibrillation (irregular heart beat), Gastro-Esophageal Reflux, Insomnia, Hypertension (high blood pressure), and Muscle Weakness. Review of Resident R15's Minimum Data Set (MDS) completed on August 2, 2024 revealed a Brief Interview with Mental Status (BIMS) score of 14, which indicated that the resident was cognitively intact. Observation of Resident R15 on August 12, 2024 at 11:08 a.m. revealed to the resident was in her recliner chair seated with her tray table next to her. Observation of the resident's tray table revealed a large white pill split in half sitting on the tray table. Licensed nurse, Employee E6 was called to the room on August 12, 2024 at 11:12 a.m. and confirmed the medication was left bedside. Licensed nurse, Employee E6 stated to the resident, you know you are not supposed to have these. Interview with licensed nurse, Employee E6 at 11:15 a.m. in the hallway revealed that licensed nurse, Employee E6 stated, I thought she took all of her medications when I watched her, she is difficult and takes her pills one at a time. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, clinical record review and interview with staff, it was determined that the facility did not develop a comprehensive care plan related to hospice care for one of two residents on hospice reviewed (Resident R26). Findings include: Review of facility policy titled Care Plans, Comprehensive Person-Centered, revised December 2017, revealed that Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Review of facility policy titled Hospice Program, revised July 2017, revealed that Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility . Review of clinical documentation revealed that Resident R26 was admitted to the facility on [DATE], and had diagnoses including, dementia, anemia, anxiety, depression, cognitive communication deficit, and palliative care. Review of Resident R26 physician orders revealed that an order dated February 28, 2024, which stated Please consult hospice for senile degeneration of the brain. Physician orders placed on March 1, 2024, included Ativan 0.5mg (milligrams) tab .by mouth every six hours as needed, Hyoscyamine 0.125mg sublingual tablet .every four hours as needed, and Morphine concentrate 100mg/5mL .0.25mL by mouth every 2 hours as needed. Interview with the Nursing Home Administrator (NHA), Employee E1, at 12:15 p.m. on August 15, 2024, revealed that the above medication orders were requested by the hospice provider and ordered by the physician, Employee E9, on March 1, 2024, when resident R26 was signed onto hospice care. At this time, Employee E1confirmed that it is the expectation of the facility that a comprehensive care plan be developed for all resident needs, including hospice care. 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records and facility policies and procedures and interviews with staff, it was determined that the facility failed to ensure that the resident's instructions for Advance Directive (one's wishes on life-sustaining medical or surgical treatment), were accurately reflected in the clinical record for one of 15 residents' records reviewed (Resident R14 ). Findings include: Review of facility policy, Policy: Advanced Directives, dated adopted July, 2008, stated that the facility will ensure that a resident's choices concerning the development of an Advance Directive relative to his or her medical care requests and /or refusal of medial treatment are followed in accordance with the facility's Advance Directive policy and procedure and current State and Federal laws. The same policy also stated that a physician's orders [REDACTED]. Review of the clinical record for Resident R14 revealed that the resident was readmitted to the facility on (MONTH) 18, 2019 with [DIAGNOSES REDACTED]. Review of a POLST (Pennsylvania Orders for Life Saving Treatment) form, signed and dated by the resident's son on (MONTH) 31, (YEAR), indicated DNR (Do Not Resuscitate - do not perform chest compressions to keep heart beating) and Limited Additional Interventions - Do not use intubation, advanced airway interventions, or mechanical ventilation. Review of the physician's orders [REDACTED].(code status - level of emergency medial interventions one wishes if breathing or the heart stops beating). Further review of Resident R14's clinical record revealed a written physician's orders [REDACTED]. Interview with the Director of Nursing on (MONTH) 20, 2019, at approximately 1:00 p.m., confirmed that the physician's orders [REDACTED]. The facility failed to ensure that residents' wishes for resuscitation upon life-threatening medical conditions were accurately reflected in the resident's clinical record. CFR(s): 483.10(c)(6) Advance Directives Previously cited 1/28/19 28 Pa. Code 201.18(b)(1) Management Previously cited 1/28/19, 12/3/18 28 Pa. Code 201.29(j) Resident rights Previously cited 1/28/19 28 Pa. Code 211.5(f) Clinical records Previously cited 1/28/19 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 1/28/19 28 Pa. Code 211.12(d)(3)(5) Nursing services Previously cited 02/08/18

Based on review of clinical records, facility policies and procedures and facility documentation, and interviews with staff, it was determined that the facility failed to ensure that neurological check reports were accurately documented, for one of 18 resident records reviewed (Resident R24) Findings include: Review of facility policy, Neurological Assessment, dated last revised (MONTH) 2010, revealed that following any unwitnessed fall, follow-up neurological assessments would be performed by staff and would be documented in the resident's clinical record. Review of undated facility document, Neurological Assessment Flowsheet, revealed neurological checks (taking blood pressure, temperature, pulse, respirations; and assessing level of consciousness, pupil response, hand grasps, motor functions, and pain response) were to be performed for any unwitnessed fall, and post-incident neurological checks would be done immediately after the incident and at the following frequency thereafter: every 15 minutes times four (one hour total); then every hour times two (two hours total); then every four hours times four (16 hours total). Review of the clinical record for Resident R24 revealed a quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated (MONTH) 15, 2019, indicating the resident had [DIAGNOSES REDACTED]. (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait). The quarterly MDS additionally indicated that Resident R24 had experienced one fall with injury since the prior MDS assessment was completed. Review of a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of a fall nursing note dated (MONTH) 13, 2019, revealed that Resident R24 sustained an unwitnessed fall at approximately 7:30 p.m., with the resident noted to be lying in a right lateral (side) position, with his head towards his recliner chair, and that Resident R24 was unable or unwilling to say what occurred however; he admitted to hitting his head. The fall nursing note went on to state that Resident R24 was sent to an acute care hospital for evaluation due to anticoagulant therapy and associated risks (possibility of bleeding in the brain). Review of a daily nurse note dated (MONTH) 14, 2019, at 1:51 a.m. revealed Resident R24 returned from the hospital with no new orders. Review of the Neurological Assessment Flowsheet for Resident R24 revealed no documentation that neurological checks were performed as scheduled at the following times: (MONTH) 14, 2019, at 1:51 a.m. (upon return from the hospital); and at 5:00 a.m. on (MONTH) 14, 2019. The neurological check scheduled for (MONTH) 14, 2019, at 1:00 p.m. included only blood pressure and pulse, and stated the reason the check was not completed was because the resident was sleeping. Interview with the Director of Nursing on (MONTH) 21, 2019, at approximately 1:30 p.m., confirmed that the neurological checks were not documented per facility policy for Resident R24. The facility failed to ensure that Resident R24's neurological flow sheet contained complete documentation in accordance with the fall incident sustained by the resident on (MONTH) 13, 2019. 28 Pa. Code 211.5(f) Clinical records Previously cited 01/28/19 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 01/28/19, 12/03/18 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 01/28/19

Based on review of clinical records and interviews with staff, it was determined that the facility failed to ensure that care plans were developed to reflect the needs of a resident in the area of recurrent infection, for one of 18 resident records reviewed (Resident R31) Findings include: Review of the clinical record for Resident R31 revealed the resident had [DIAGNOSES REDACTED]. Review of a Certified Registered Nurse Practitioner (CRNP) progress note, dated (MONTH) 13, 2019, revealed Resident R31's personal companion reported that the resident was frequently rubbing her eyes, and that nursing reported that the resident was noted with periorbital [DIAGNOSES REDACTED] (redness and swelling around the eye sockets). The CRNP progress note went on to state that Resident R31 had a [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of another CRNP progress note dated (MONTH) 11, 2019, revealed nursing staff reported that Resident R31 had periorbital redness, and that the resident had a [DIAGNOSES REDACTED]. Review of the plan of care for Resident R31 revealed no care plan was developed for the resident's recurrent periorbital/preseptal [MEDICAL CONDITION]. Interview with the Director of Nursing on (MONTH) 21, 2019, at approximately 12:30 p.m. confirmed there was no documentation that a care plan was developed for Resident R31's recurrent periorbital/preseptal [MEDICAL CONDITION]. The facility failed to develop and implement a comprehensive person-centered care plan for Resident R31. 28 Pa. Code 211.5(f) Clinical records Previously cited 01/28/19 28 Pa. Code 211.11(c) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 01/28/19, 12/03/18

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to accurately document a resident's status, for two of four hospice clinical records reviewed (Residents R4 and R7). Findings include: Review of the clinical record review for Resident R4, revealed the resident had [DIAGNOSES REDACTED]. Review of a hospice (end of life care to support resident and family) recommendations form dated (MONTH) 16, 2019, revealed Resident R4 was admitted to receive hospice care for the [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set assessment (MDS-periodic assessment of needs) dated (MONTH) 23, 2019, revealed that under Section O, Special Treatments, Procedures, and Programs, line K for Hospice care was not checkmarked. Interview with Employee E3, Registered Nurse Assessment Coordinator, on (MONTH) 21, 2019, at 10:24 a.m. revealed the significant change MDS was completed for Resident R4's initiation of hospice care, and confirmed that line K on the MDS was not marked to indicate hospice care. Review of the clinical record review for Resident R7, revealed that the resident had [DIAGNOSES REDACTED]. Further review of resident's clinical record revealed that Resident R7 was admitted to hospice(end of life care and services) on (MONTH) 6, 2019. Review of a significant change Minimum Data Set assessment (MDS-periodic assessment of needs) dated (MONTH) 17, 2019, revealed that under Section O: Special Treatments, Procedures, and Programs, line K for Hospice care was not checked as being performed within the last fourteen days as directed by the instructions. Interview with Employee E3, Registered Nurse Assessment Coordinator, on (MONTH) 21, 2019, at 1:20 p.m. confirmed that the significant change MDS was not completed accurately for Resident R7 regarding hospice care. The facility failed to ensure the accuracy of Resident R4 and R7's MDS assessments. 28 Pa. Code 211.5(f) Clinical records Previously cited 01/28/19 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 01/28/19, 12/03/18

Based on review of clinical records and interviews with staff, it was determined that the facility failed to ensure that residents' wishes for Advance Directives (one's wishes on life-sustaining medical or surgical treatment), were reflected accurately in the clinical record for two of 14 resident records reviewed (Residents R7 and R19). Findings include: Review of Resident R7's clinical record revealed the resident was admitted to the facility on (MONTH) 20, (YEAR). Review of the resident's clinical record revealed an advance health care directive which describes health care treatment instructions in the event of end-stage medical condition or permanent unconsciousness. The advance directive which was signed by resident and dated (MONTH) 25, (YEAR), revealed the resident wishes were to be a do not resuscitate (DNR - do not perform lifesaving interventions in the event the resident has no pulse and had stopped breathing). Further, review of Resident R7's clinical record revealed no physician order for [REDACTED].>Interview on (MONTH) 25, 2019, at 1:30 p.m. with Employee E3, RN, where she confirmed the resident's wishes were to be a DNR and Employee E3 confirmed that there was no physician order for [REDACTED]. Review of Resident R19's clinical record revealed a current physician's order, dated (MONTH) 6, (YEAR), indicating that the resident is a full code (allows for all interventions needed to restore breathing or heart functioning, including chest compressions, a defibrillator and insertion of a breathing tube). Continued review of Resident R19's clinical record revealed a POLST form (Pennsylvania Orders for Life-Sustaining Treatment), signed and dated by a nurse practitioner (MONTH) 31, (YEAR), which indicated that the resident wants to be DNR status. Interview on (MONTH) 25, 2019, at 10:00 a.m. with the Director of Nursing confimed that the physician's order for Resident R19 should have been updated after the POLST form was signed to reflect the resident's wishes to be DNR status. The facility failed to ensure accurate documentation was maintained regarding the resident's wishes for resuscitation upon life-threatening medical conditions. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/3/18, 11/1/17 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 12/3/18, 11/1/17 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management Previously cited 12/3/18, 11/1/17 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(j) Resident rights Previously cited 11/1/17 28 Pa. Code 211.5(f) Clinical records Previously cited 11/1/17 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/3/18, 11/1/17 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 11/1/17

Based on interviews with staff, review of clinical records, and facility documents, it was determined that two residents were injured as a result of the facility's failure to provide adequate assistance with transfers for one resident (Resident R1) resulting in a displaced right humerus fracture and adequate supervision for another resident (Resident R2) resulting in a fall and a subarachnoid hemorrhage while the residents were receiving personal care for 2 of 2 records reviewed. (Residents R1 and R2). Findings include: Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - periodic assessment of resident's needs) dated 8/26/18, revealed that the resident required two person physical assistance with transfers, dressing, full bath/shower and toilet use. The care plan stipulated that this resident required two people to transfer the resident with a sit to stand lift device. A review of the nurse's note dated 11/17/18, at 11:20 AM stated that there was right medial elbow bruising. Vitals 97.9-73-18-140/74, 95% on room air. Nurse aide (NA) noted right medial elbow bruising during AM care. The resident did complain of pain in the bruised area. Employee E3 (Certified Registered Nurse Practitioner) was notified. A new order was obtained for [MEDICATION NAME] 50 mg-1 tab by mouth now x1 dose (a pain medication). Reviewed of the telephone order indicated that the order was written at 9:00 AM. A nurse's note dated 11/17/18, at 3:15 AM indicated that the bruising on the right medial elbow was more pronounced, and swelling was noted. The area was painful, and the resident expressed discomfort with movement. Employee E3 was notified. A new order was received for [MEDICATION NAME] 50 mg-1 tablet by mouth every 6 hours when needed for pain. A nurse's note dated 11/17/18, during the 3-11 shift, stated that the resident was noted with what appeared to be [MEDICAL CONDITION] activity during dinner. The resident was removed from the dining room and assessed. Vital signs: 96.8-48-16-145/96, 96% on room air. Periodic [MEDICAL CONDITION] activity continued, medical personel on call made aware who advised that the resident be sent to the emergency room for evaluation if the family /power of attorney was agreeable. The resident was transfered to the emergency room at 6:20 PM. A physcian's note dated 11/21/18, stated that the resident was hospitalized for [REDACTED]. She was admitted at night with shaking, right arm pain, ecchymosis (discoloration of skin caused by bruising) and lethargy. The orthopedic consult and X-rays completed at the hospital determine that the resident sustained [REDACTED]. The Incident and Accident Report dated 11/17/18, at 8:00 AM revealed that the nurse aide assigned to the resident on Friday night 11/16/18, was given report that the resident was having shoulder pain. The nurse aide stated that she did not move the resident at night because she was sleeping. At 6:00 AM, the nurse aide provided incontinent care. During the care the resident complained of pain; the nurse aide notice a small purple area on the elbow and notified the charge nurse. The investigation revealed that the nurse aide that provided care to the resident on 11/16/18, during the 3-11 shift, stated that she transferred the resident with a sit to stand lift device, onto and off of the toilet by herself, without any assistance. The resident's private duty companion was with the resident on the evening of 11/16/18, and she stated that the nurse aide placed the resident in the device; wheeled her into the bathroom; provided care, wheeled her back to bed and put her in bed. When the resident layed down in the bed, she complained that her arm was hurting. The private duty companion also said that the nurse aide was working alone. An interview was conducted with Employee E3 on (MONTH) 3, (YEAR), at 11:40 AM. Employee E3 stated that he sees the resident when incidents pop up. Monthly assessments are completed by the attending physician. He also stated that on (MONTH) 17, (YEAR), he was on call for the weekend and he did not see the resident. An interview was conducted with the Director of Nursing, Employee E2, on (MONTH) 3, (YEAR), at approximately 12:00 noon regarding the investigation. Employee E2 stated that as a part of the investigation she reviewed the facility monitor and saw that the resident was moving her right arm around 6:30 PM and she saw the private duty nurse wheel the resident into the room at 7:30 PM. Once they enter the room, they are out of the view of the monitor. Employee E2 confirmed that Resident R1 required two person assistance for transfers and the nurse aide assigned to the resident on (MONTH) 16, (YEAR), on evening shift, transferred the resident alone. The facility failed to provide adequate assistance for safe transfer resulting in actual harm to Resident R1's upper arm. Resident R2 was admitted to the facility on (MONTH) 25, (YEAR). [DIAGNOSES REDACTED]. A review a significant change MDS dated [DATE], revealed that the resident required two person physical assistance with transfers, full bath/shower and toilet use. The care plan stipulated that this resident required two people to transfer the resident with a sit to stand lift device. A review of nurse's a note dated 11/16/18, during the 7-3 shift, stated that the nurse was called at 8:15 AM to the resident's room. The resident was on the bathroom floor. The resident was awake, alert and oriented x3, no complaints of pain at this time. The resident was noted with a laceration on the left side of the forehead approximately 2.5 cm. Actively bleeding. The resident was on blood thinners. The resident was transferred to the bed by three people, head and neck stabilized, pressure dressing applied. Vital signs; 97.5-78-22-173/78 -93% on room air. The nurse asked the resident how did she fall? The resident stated she was on the john (toilet) and the seat was uncomfortable so she attempted to get up. The nurse noted that the resident was actually sitting on a shower chair practically dressed at the time. Employee E3 was notified. The CRNP (Employee E3) note written on 11/16/18, stated that he was asked to see the resident for a fall with a strike to the head. The resident was bleeding profusely from the head. The resident denied pain. Assessment: swelling around left orbit (bony socket of the eye). Sent to the hospital. At the time of the incident, the resident was receiving Eliquis 5mg (a blood thinner) twice a day for [MEDICAL CONDITION] (irregular heart rhythm that causes poor blood flow). The Incident and Accident Report dated 11/16/18, at 8:15 AM described the incident in the following manner: the resident said that she thought that she was on the john, it got uncomfortable and she tried to get up. The resident was noted on her left side on the bathroom floor by the nurse aide and license practical nurse. The resident was assessed and assisted back to bed. The resident has a laceration to the left side of the forehead, a pressure dressing was applied to the site. Evaluated by Employee 3. The resident was sent to the hospital. The physician's note dated 11/19/18, stated that the resident had a subarachnoid hemorrhage (refers to bleeding within the subarachnoid space between the brain and the tissues that cover the brain) secondary to a fall from a seated position that occurred on 11/16/18. The investigation revealed that the nurse aide assigned to Resident R2 stated that the resident was showered and she was dressing her in the bathroom. The nurse aide left the resident on the shower chair unattended and went to the resident's closet for another pair of pants instead of calling for assistance. The nurse aide stated she did not call for assistance because she never thought that the resident would get up from the shower chair. The facility failed to provide adequate supervision and assistance during Resident R2's shower to prevent a fall resulting in actual harm to Resident R2 who sustained a subarachnoid hemorrhage. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/01/17 28 Pa. Code 201.18(b)(1)(3) Management previously cited 11/01/17 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/1017

Based on interviews with staff, review of a clinical record and facility documents, it was determined that the facility did not ensure that a radiology study was obtained in a timely manner for one resident with persistent arm pain resulting from a displaced right humerus fracture for one of two clinical records reviewed resulting in actual harm.(Resident R1). Findings include: Resident R1 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. The Incident and Accident Report dated 11/17/18, at 8:00 AM revealed that the nurse aide assigned to the resident on night shift was given report that the resident was having shoulder pain. At 6:00 AM on 11/17/18, the resident complained of pain during care; the nurse aide noticed a small purple area on the elbow and notified the charge nurse. A review of the nurse's note dated 11/17/18, at 11:20 AM stated that there was right medial elbow bruising. Vitals 97.9-73-18-140/74, 95% on room air. Nurse aide (NA) noted right medial elbow bruising during AM care. Resident did complain of pain in bruised area. Employee E3 (Certified Registered Nurse Practitioner) notified. New order: [MEDICATION NAME] 50 mg-1 tab by mouth now x1 dose. Reviewed of telephone order dated 11/17/18, indicated that the order for pain medicine was written at 9:00 AM. A nurse's note dated 11/17/18, at 3:15 PM stated bruising on right medial elbow more pronounced. Swelling noted. Area painful - resident expressed discomfort with movement. Employee E3 notified. New order: [MEDICATION NAME] 50 mg-1 tablet by mouth every 6 hours when needed for pain. A nurse's note dated 11/17/18, during the 3-11 shift, stated the resident was noted with what appeared to be [MEDICAL CONDITION] activity during dinner. The resident was removed from the dining room and assessed. Vital signs: 96.8-48-16-145/96, 96% on room air. Periodic [MEDICAL CONDITION] activity continued, medical personal on call made aware who advised that the resident be sent to the emergency room for evaluation if family/power of attorney is agreeable. The resident was transfer to the hospital at 6:20 PM. An orthopedic consult was completed on 11/18/2018, at 11:44 AM. The physician wrote that the resident was brought to the emergency department for evaluation after she reportedly had [MEDICAL CONDITION] activity at her living facility. She was noted to have bruising over her anterior forearm so X-rays were performed. She was found to have a humeral (the bone in the upper arm) shaft fracture. A physcian's note dated 11/21/18, stated that the resident was hospitalized for [REDACTED]. She was admitted at night with shaking, right arm pain, ecchymosis (discoloration of skin caused by bruising) and lethargy. The orthopedic consult and X-rays completed at the hospital determined that the resident sustained [REDACTED]. An interview was conducted with the Certified Registered Nurse Practitioner, Employee E3 on (MONTH) 3, (YEAR), at 11:40 AM. Employee E3 stated that he sees the resident when incidents pop up. Monthly assessments are completed by the attending physician. He also stated that on (MONTH) 17, (YEAR), he was on call for the weekend and he did not see the resident. The facility failed to order an X-ray in a timely manner for Resident R1 by medical personnel after receiving reports that the resident had persistent pain with acute anomalous changes to the resident's arm. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/01/17 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 11/01/17 28 Pa. code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/01/17

Based on interviews with staff, review of a clinical record and facility documents, it was determined that the facility failed to obtain the necessary services to address the behavioral health care needs for one of two clinical records reviewed (Resident R2). Findings include: Resident R2 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed a significant change Minimum Data Set assessment (MDS -mandate review of a resident's care needs) dated 8/23/2018, which indicated that the resident's cognition was moderately impaired. The resident's medication regimen included [MEDICATION NAME] 25mg (antipsychotic) at bedtime; [MEDICATION NAME] 150 mg (antidepressant) daily and Donepezil [MEDICATION NAME] 10 mg (anti-alzheimer medicine) daily. An neurologist consult dated (MONTH) 29, (YEAR), noted that the resident complained of anxiety and agitation. He ordered to increase the [MEDICATION NAME] to 150 mg daily for 2 weeks; it will be effective and hopefully reduce and/or stop [MEDICATION NAME]. Neurologist consult dated (MONTH) 25, (YEAR), did not mention behavioral health issues but ordered [MEDICATION NAME] to be discontinued. Review of the care plan indicated that the resident was receiving [MEDICATION NAME] and [MEDICATION NAME] since (MONTH) 26, (YEAR), and the resident was identifed as being verbally inappropriate with staff and other residents at times. A nurse's note dated 11/15/18, at 10:40 PM stated that the resident voiced feelings of abandonment and said, I wish I were dead. On (MONTH) 16, (YEAR), the resident fell ; sustained subarachnoid hemorrhage and was sent to the hospital. The resident returned to the facility on (MONTH) 17, (YEAR). The nurse's note dated (MONTH) 18, (YEAR), during the 3-11 shift, indicated that the resident was agitated prior to dinner and she verbalized that she felt abandoned. On (MONTH) 21, (YEAR), the resident verbalized that she wanted to die. The Certified Registered Nurse Practioner (CRNP) was notified. On (MONTH) 21, (YEAR), the CRNP wrote chief complaint: suicidal ideation. Nursing staff reported the patient has been talking about death and suicide. The patient said these things in the past as well. No history of suicide attempt or self-harm. Resident talk of suicide in past. I believe resident is low risk for self-harm due to dementia and left [MEDICAL CONDITION]. Additionally I feel her current mood was because the hospital reduce her [MEDICATION NAME]. I will restore her [MEDICATION NAME] 150 mg daily, discussed case with social worker, may consider sending patient out to psychiatry. The CRNP did not discuss the behavioral health needs with a mental health social worker. An interview of the Director of Nursing, Employee E2 on (MONTH) 3, (YEAR), at approximately 2:30 PM revealed that the facility does not have a psychiatrist on staff and a psychologist was obtained only through referrals. Employee E2 stated that [MEDICAL CONDITION] medicine was being managed by the attending physician, CRNP and the neurologist. Employee E2 stated that the facility has not had a psychiatrist since early summer. Interview with the Nursing Home Administrator, Employee E2 on (MONTH) 3, (YEAR), confirmed that the facility has not has a psychiatrist on staff since early summer. An interview with Employee E1 on (MONTH) 4, (YEAR), at approximately 10:30 AM via telephone. Employee E1 verified that Resident R2 was not on hourly checks. The facility failed to obtain the necessary behavioral health services to manage [MEDICAL CONDITION] medicines; address behavioral/ mental issues and to provide continuity of care. 28 Pa. Code 201.14 (a) Responsibility of licensee Previously cited 11/01/17 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management Previously cited 11/01/17 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/01/17

Based on review of the facility documentation and staff interview, it was determined that the facility failed to ensure that the Medical Director/Physician and/or his designee attended the Quality Assessment and Assurance Committee quarterly meetings. Findings include: Review of the facility policy and procedure, titled, Quality Improvement, dated, September 16, 2015, indicated, It shall be the policy of this facility to strive to provide outstanding quality of care and services to all residents and their families/representatives. It shall be the policy of this facility to strive to provide a workplace environment for our staff that is conducive to the effective and efficient provision of quality care and services. It shall be the policy of this facility for the Continuing Quality Improvement Committee to meet at least quarterly and additionally as may be necessary with participants to include but not limited to: The Administrator, The Director of Nursing, The Medical Director and/or his designee, The Consult Pharmacist, all department Managers involved in Health Services and Additional staff as appointed by Administration. The purpose of the Quality Assessment and Assurance Committee is an evaluation of a process and/or outcomes of a process to determine if a defined standard of quality is being achieved. An interview with the Medical Director on October 30, 2017, at 1:40 p.m. indicated, That he is to attended quarterly Quality Assessment and Assurance Committee, when pharmacy and labs are in attendance. Review of the job description for the Medical Director, indicated, he or she is to provide leadership and direction to the Beaumont at Bryn Mawr community's health services departments so that the mission of the institution is reflected in long-range, strategic and operational plans; including services design, resource allocation and organizational policies. Establish expectations, plans, priorities and monitor performance of health services per community wide standards. A review of Continuous Quality Improvement, (Quality Assessment and Assurance Committee), monthly minutes, with the Nursing Home Administrator, on October 31, 2017, at 10:30 a.m. revealed that the Medical Director/Physician and/or his designee, was not in attendance for Quality Assessment and Assurance Committee, since the last Full Health Survey, October 7, 2016 - August 16, 2017. The facility failed to ensure that The Medical Director/Physician and/or his designee attended Quality Assessment and Assurance Committee, on a quarterly basis. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/3/15 28 PA. Code 201.18(a)(b)(1)(3)(e)(1)(2)(3) Management Previously cited 12/3/15

Based on a group interview with alert and oriented residents, review of facility documentation and interviews with facility staff, it was determined that the facility failed to provide an ongoing activities program for residents that was meaningful and designed to meet the individual needs and physical, mental and psychosocial well being for five of five residents attending the group interview (Residents R1, R6, R18, R24 and R26) and for Resident 32. Findings include: A review of the facility policy and procedure titled, Activities, undated, indicated that the goal of the Activities Department was to, provide a balanced program of daily activities considering the physical, intellectual, emotional and spiritual needs of the resident. During the group meeting with five alert and oriented residents, (Residents R1, R6, R18, R24 and R26), on October 30, 2017, at 3:00 p.m. it was revealed by all five residents that the Activities Department, falls apart on the weekends, evening activities are not offered and no variety to the activities that are offered. Review of the clinical record for Resident R32 revealed a quarterly Minimum Data Set assessment (MDS-periodic assessment of needs, dated August 20, 2017, revealed that the resident was cognitively intact. Interview with Resident R32 on October 31, 2017, at approximately 8:30 a.m., revealed that the resident had concerns regarding the activities program provided by the facility. Specifically mentioned by Resident R32 was that the facility had provided church services on Sundays, along with a live piano player for residents to sing hymns during the service, and that this activity had stopped recently. Resident R32 indicated in the interview that he/she wanted to see the church service reinstated. A review of the Activities calendars from August 1, 2017 - October 31, 2017, revealed that activities that were offered were repetitive on a weekly basis. Such as on Friday's in October, 9:30 a.m. Let's Chat, 10:00 a.m. Coffee Club, 11:00 Exercise with Mimose, 11:30 a.m. Mind Stretchers, 2:00 p.m. Friday Flick, 3:30 p.m. Happy Hour and 4:30 p.m. Resident Choice. Further review of the calendar's revealed that no evening activities were ever offered and no religious services were offered. An interview with Employee E3, Director of Activities, on November 1, 2017, at 11:30 a.m. confirmed that the Activities calendars are repetitive and no religious services are offered. Review of each of the five residents, clinical records, that attended the group meeting, (Residents R1, R6, R18, R24 and R26), revealed Therapeutic Recreation Assessments, that were completed individually, by Employee E3. Each resident indicated, to Employee E3, activities of choice, preference and hobbies. Further review of each of the five clinical records revealed, individual care plans that were developed at the time of admission, which also indicates each resident's activities of desire. Employee E3, further indicated understanding the sentiment that the 6 alert and oriented residents expressed about the Activities department not meeting their individual and group desires related to the scheduled activities. The facility failed to ensure that activities were being offered in the evenings and that activities were meaningful and designed to meet the individual needs and physical, mental and psychosocial well-being of the residents. 28 Pa. Code 201.18(a)(b)(e)(1)(2)(3) Management Previously cited 12/3/15 28 Pa. Code 201.29(i)(j) Resident rights Previously cited 12/3/15

Based on review of clinical records and facility documentation, and interviews with staff, it was determined that the facility failed to ensure that adequate communication was maintained between a hospice (end of life care to support resident and family) provider and the facility, for one of 14 clinical records reviewed (Resident R17). Findings include: Review of a Hospice and Nursing Facility Services Agreement between the facility and a hospice provider, dated as updated September 23, 2014, revealed that the hospice provider would make clinical records and information available to the facility regarding care and services provided to a resident receiving hospice services. Review of the clinical record for Resident R17 revealed a significant change Minimum Data Set assessment (MDS-periodic assessment of needs) dated September 16, 2017, indicating [DIAGNOSES REDACTED]. Review of hospice documentation indicated Resident R17 was admitted to hospice care on September 14, 2017. Review of the facility's plan of care for hospice services for Resident R17 dated September 14, 2017, revealed that hospice care would be provided to the resident for comfort and support, and that the facility would collaborate with the hospice provider to coordinate services. Further review of the clinical record for Resident R17 revealed no documentation of care that had been provided by hospice staff (licensed nurses, nursing assistants or social workers) in the resident's clinical record. Interview with the Director of Nursing on November 1, 2017, at approximatley 12:00 p.m. confirmed there was no documentation available for review in the facility regarding the care and services that were provided to Resident R17 from hospice staff. The facility failed to ensure that adequate communication was maintained between a contracted hospice provider and the facility for one resident. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/03/15 28 Pa. Code 201.18(b)(1) Management Previously cited 12/03/15 28 Pa. Code 201.21(a)(b)(c) Use of outside resources 28 Pa. code 211.5(f) Clinical records Previously cited 12/03/15 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 12/03/15

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to follow and/or clarify physician's orders related to [MEDICAL CONDITION] (continuous positive airway pressure-machine to treat sleep disorders) machines and pacemakers (surgically implanted electronic device to stimulate the heartbeat), and failed to assess and monitor peripherally inserted central catheter (PICC-tube inserted into a vein for long term use) lines, for two of 14 residents reviewed (Residents R37 and CL3). Findings include: Review of Resident R37's clinical record revealed an admitted [DATE]. Further review of Resident R37's clinical record revealed a physician order for [REDACTED]. [REDACTED]. An interview with the Director of Nursing on October 31, 2017, at 2:00 p.m. confirmed there were no physician's orders related to the pressure settings for Resident R37's [MEDICAL CONDITION] machine. Continued review of Resident R37's physician orders dated, June 2, 2017, at the time of admission, indicated a [DIAGNOSES REDACTED]. in the chest or abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate). During review of Resident R37's clinical record, under the consult section of the clinical record, revealed a Cardiology consult sheet dated, April 17, 2017, which indicated, a schedule for Remote Care Schedule for Resident R37's pacemaker. An interview with the Director of Nursing on October 31, 2017, at 2:00 p.m. confirmed physician's orders were not followed related to Resident R37, having pacemaker checked, every two months, as suggested by Cardiologist. Review of undated facility nursing policy, Peripherally Inserted Central Catheter (PICC) Line Dressing Change, revealed that nursing staff would change the dressing over the PICC line every seven days, or sooner if the dressing became loose, soiled or wet. The policy further stated that during the dressing change procedure, nursing staff would measure the external length of the catheter (amount of tubing that is visible outside of the body) to rule out or confirm suspected catheter slippage (accidental migration of the catheter), compare the current measurement with the documented length, and report any discrepancies to the nursing supervisor. Review of the clinical record for Resident CL3 revealed the resident was admitted to the facility on [DATE], from an acute care hospital, with [DIAGNOSES REDACTED]. Review of an interdisciplinary care plan for Resident CL3's right upper extremity PICC line, dated April 12, 2017, revealed the resident's dressing over the PICC line would be changed as ordered by the physician. Review of a physician's order, dated April 17, 2017, instructed staff to measure the resident's external length of the PICC catheter with each transparent (able to see the skin through the dressing) dressing change, every seven days. Review of a PICC Line Dressing Change/Measurement Record revealed on admission to the facility on [DATE], Resident CL3's external catheter measurement was documented as zero centimeters (no length of catheter was visible outside the body). Further review of the PICC Line Dressing Change/Measurement Record revealed on April 24, 2017, the external length of the catheter was documented as measuring 5.0 centimeters (cm), a 5.0 cm difference from admission. Further review of the clinical record for Resident CL3 revealed no documentation that the nursing supervisor, certified registered nurse practitioner, or physician were made aware of the 5.0 cm external catheter length as noted on April 24, 2017. Interview with the Director of Nursing on November 1, 2017, at approximately 12:30 p.m., confirmed there was no documentation that nursing staff notified the physician or other designee related to a possible 5.0 cm migration of Resident CL3's PICC line. The facility failed to ensure that each resident achieved the highest possible level of functioning and well-being by not providing the necessary care and services related to obtaining [MEDICAL CONDITION] machine settings, obtaining pacemaker checks, and assessing and monitoring PICC lines for potential complications. 483.24, 483.25(k)(1) Provide Care/Services for Highest Well Being Previously cited 12/03/15 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/03/15 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/03/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/03/15 28 Pa. Code 211.12(d)(2)(3) Nursing services

Based on a review of clinical records, facility documentation, and facility policies and procedures, and interviews with staff, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for potential violations of resident abuse and neglect, for one of 14 residents reviewed (Resident R41). Findings include: Review of the facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated effective November 28, 2016, revealed that an injury of unknown origin (including, but not limited to, multiple unexplained bruises), would be immediately investigated to rule out abuse or neglect, and that the results of the investigation would be recorded. Review of the clinical record for Resident R41 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of physician's orders, dated July 6, 2017, and monthly thereafter, instructed staff to administer aspirin (over-the-counter pain medication used for its blood thinning properties) 81 mg (milligrams), one tablet orally every day, for a [DIAGNOSES REDACTED]. Review of the resident's plan of care for transferring (how one moves from bed to chair or other resting place), dated August 1, 2017, indicated Resident R41 required a sit-to-stand lift (mechanical assistive device that allows staff to transfer a resident) for staff to safely facilitate a transfer. Review of nurse's notes revealed on August 17, 2017, at 12:00 p.m., the resident was noted with a bruise to the right arm measuring 6 centimeters by 5 centimeters. Review of a nurse's note dated August 17, 2017, at 8:05 p.m., revealed Resident R41 was noted with three bruises on the right arm: one located on the right upper am, one located on the right medial (inner side) forearm, and one located on the right lateral (outer side) forearm. Review of facility documentation revealed no evidence that the facility conducted an investigation to determine how the above bruises as noted on Resident R41's right arm might have occurred. Interview with the Director of Nursing on November 1, 2017, at approximately 1:15 p.m., confirmed that there was no documentation that a complete and thorough investigation was conducted to rule out abuse or neglect related to bruising found on Resident R41. The facility failed to conduct a complete and thorough investigation to rule out resident abuse and neglect for an injury of unknown source. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/03/15 28 Pa. Code 201.18(a)(b)(3)(e)(1) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 12/03/15 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited 12/03/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/03/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 12/03/15

Based on observation, review of clinical records, facility documentation and facility policies and procedures, and interviews with staff, it was determined that the facility failed to provide adequate supervision to ensure the safety of a resident, identified as at risk for elopement (exiting a building without staff knowledge), resulting in actual harm for one of 12 residents reviewed (Resident CL1). Findings include: Review of facility policy and procedure, Elopement, updated [DATE], revealed that residents at risk of elopement would receive appropriate interventions to reduce risk and minimize injury, and in the event of a resident elopement, and when the resident was found, staff would perform a physical examination of the resident and document the findings in the resident's clinical record. Review of the clinical record for Resident CL1 revealed the resident was originally admitted to the facility in [DATE], with [DIAGNOSES REDACTED]. Review of a Risk of Elopement/Wandering Review sheet, dated last reviewed [DATE], indicated Resident CL1 ambulated (walked) independently with or without the use of an assistive device (including a wheelchair), and had a history of [REDACTED]. Review of the interdisciplinary care plan for Resident CL1, dated last reviewed [DATE], revealed the resident had an alteration in safety awareness related to cognitive impairment and forgetfulness, was noncompliant with care, and preferred to leave the unit unsupervised against advice of staff members. Resident CL1's interdisciplinary care plan indicated that a goal was to keep the resident safe and if the resident left the unit, staff would know where the resident was going and estimated time of return. Review of a physician progress notes [REDACTED]. The physician progress notes [REDACTED]. Review of nurse's notes revealed on [DATE], at 11:00 p.m., Resident CL1 was noted with mild confusion, was ambulating on the unit looking for a group of people, and staff had to redirect the resident several times. On [DATE], at 11:20 p.m., a nurse's note indicated the resident had ongoing confusion and had to be redirected by staff. On [DATE], at 10:55 a.m., a nurse's note indicated Resident CL1 was documented to appear, very drowsy this morning and forgetful, with some confusion noted, and that staff were awaiting the results of a urinalysis culture and sensitivity (urine test to determine the presence of infection in the urine, and what antibiotic medication would be appropriate for treatment) that had been sent to the lab per physician's orders [REDACTED]. urinalysis (indicating the presence of an infection) and hematuria (blood in the urine). On [DATE], at 2:15 p.m., a nurse's note indicated the resident's International Normalization Ratio (INR-laboratory test to determine the effectiveness of blood thinning medication) was 3.1 (normal range ,[DATE]), indicating an increased risk of bleeding, with hematuria over the weekend, that the resident's Coumadin would be held that evening, to restart Coumadin 2 milligrams (administered once daily) on [DATE], and to recheck the INR on [DATE], per physician's orders [REDACTED]. Review of a facility event report revealed on [DATE], on the 11 p.m. to 7:00 a.m. shift, Resident CL1 was very confused and agitated, and was trying to leave the facility by walking toward the facility's front door, stating the resident had to get to work and needed to get to the resident's car. The event report indicated the resident was wearing pajamas, a sweater, shoes and was holding a bag. Review of a nursing employee witness statement (Employee E1) dated [DATE], revealed that Resident CL1 was noted with some confusion, was redirected to the resident's room but refused to go to bed, and that Employee E1 reminded a certified nursing assistant that, we should keep an eye on the resident. Review of another nursing employee witness statement (Employee E2-nursing supervisor) dated [DATE], revealed that at approximately 1:00 a.m., Employee E2 was notified by floor staff that Resident CL1 was trying to leave the facility, and Employee E2, ran and pursued the resident. Employee E2's statement indicated that the resident was very difficult to redirect, was taken back to the resident's bedroom, but was seen at 1:45 a.m., at the receptionist desk area. Employee E2's statement indicated that Resident CL1 was brought into the nurse's station for supervision, and at 2:00 a.m., a delivery person from the facility's pharmacy arrived with medications. Employee E2's statement indicated that after Employee E2 signed for the medications, Resident CL1, had left the nurse's station, and a search for the resident was initiated. Employee E2's statement indicated that a facility security officer found the resident outside the building, in a ditch. Review of facility investigation documentation dated [DATE], revealed the resident was found at 2:50 a.m., approximately 50 minutes after Resident CL1 was identified as missing. Further review of the nursing employee witness statements from Employees E1 and E2 revealed both Employees E1 and E2 responded with security personnel to where the resident was found outside the building, described as observed sitting on the ground, the resident was, all wet and shivering, complained of pain to upper extremities (arms) and of being cold, that the resident was unable to grasp the nurse's hands, that 911 (emergency medical services) was called, and the resident was sent to an acute care hospital for evaluation. Review of the clinical record revealed a Neurological Assessment Flowsheet, dated [DATE], indicating that at 3:30 a.m., the resident's blood pressure was ,[DATE] and pulse was 126 (normal range 72 beats per minute), hand grasps were documented as U for unable to follow commands, and motor function of extremities (ability of arms and legs to move) was checked as abnormal; at 3:45 a.m., the resident's blood pressure was ,[DATE] (elevated) and pulse was 118, hand grasps were documented as U for unable to follow commands, and motor function of extremities was checked as abnormal; and at 4:00 a.m., the resident was at the hospital. Further review of the clinical record revealed no documentation regarding physical assessment of the resident (other than the neurological checks performed at 3:30 a.m. and 3:45 a.m.) after Resident CL1 was found outside the building, what time the ambulance arrived, and what the resident's condition was at the time of transfer to the hospital. Review of a nurse's note, dated [DATE], indicated Resident CL1 was readmitted to the facility on hospice (end of life care to support resident and family) from an acute care hospital with [DIAGNOSES REDACTED]. upper arm bone unable to be surgically repaired). Review of a physician Re-Admission history and physical examination [REDACTED]. Review of a nurse's note, dated [DATE], at 2:15 p.m., indicated Resident CL1 expired (passed away). Review of a physician's discharge summary dated [DATE], revealed the resident expired from complications of the subdural hematoma. Interview with the Nursing Home Administrator and Director of Nursing on [DATE], at approximately 11:30 a.m., revealed that during the facility's investigation into the circumstances around Resident CL1's elopement from the facility on [DATE], the investigation determined that while the nurse was attending to the pharmacy representative, the resident walked out of the nurse's station through a door that led into the main dining room, and exited the building from another door within the main dining room. This door was alarmed for resident safety to alert staff if anyone opened the door, but the investigation revealed that the alarm was not functioning at the time the resident left the building, and facility staff could not determine at what point the door's alarm had become inoperable prior to [DATE]. Observation of the dining room door in the presence of the Nursing Home Administrator and Director of Nursing revealed the door led directly outside to another entrance of the building, not the entrance to the skilled nursing facility. Further interview with the Nursing Home Administrator and Director of Nursing on [DATE], at approximately 11:45 a.m., confirmed that there was no documentation in the resident's clinical record regarding the assessment (other than the neurological checks performed at 3:30 a.m. and 3:45 a.m.) of the resident after Resident CL1 was found outside the building, what time the ambulance arrived, and what the resident's condition was at the time of transfer to the hospital. Further interview confirmed that Resident CL1 eloped from the facility without staff knowledge, and sustained multiple injuries from falling unattended outside of the building. This failure to adequately supervise Resident CL1, a resident exhibiting imminent exit-seeking behaviors, contributed to the elopement, fall necessitating surgical intervention, and eventual death, resulting in actual harm to the resident. 28 PA Code: 201.14(a) Responsibility of licensee. 28 PA Code: 201.18(b)(1) Management. 28 PA Code: 211.5(f) Clinical records. 28 PA Code: 211.10(d) Resident care policies. 28 PA Code: 211.11(c) Resident care plan. 28 PA Code: 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records and interviews with staff, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: Review of the clinical record for Resident R4 revealed that the resident was admitted to the facility on [DATE], with diagnoses, including but not limited to, diabetes mellitus (DM-failure of the body to produce enough insulin to enable sugar to pass from the bloodstream into cells for nourishment). Physician orders [REDACTED]. Further review of the physician orders [REDACTED]. Review of nursing notes dated October 29, 2015, through November 24, 2015, revealed that Resident R4's blood sugar levels exceeded the physician ordered parameters on the following occasions: a blood sugar of 356 was noted on October 29, 2015, at 4:00 p.m. and 317 at 9:00 p.m., a blood sugar of 315 on October 31, 2015, at 4:00 p.m., a blood sugar of 469 on November 2, 2015, at 4:00 p.m. and 383 at 9:00 p.m., a blood sugar of 326 on November 3, 2015, at 12:00 p.m., a blood sugar of 323 on November 4, 2015, at 12:00 p.m. and 364 at 4:00 p.m., a blood sugar of 328 on November 5, 2015, at 12:00 p.m. and 319 at 4:00 p.m., a blood sugar of 69 on November 21, 2015 at 11:40 p.m. and a blood sugar of 42 at 6:30 a.m., on November 24, 2015. Further review of the nursing notes revealed no clinical documentation that the physician had been notified of any of the above listed blood sugar results. Interview with the Director of Nursing on December 3, 2015, at approximately 1:50 p.m., confirmed that review of Resident R4's clinical record revealed no evidence that on the above listed dates, the resident's physician had been notified of the abnormal blood sugar results as ordered. The facility failed to follow physician orders [REDACTED]. 28 PA Code: 211.12(d)(1)(5) Nursing services.

Based on observation of medication administration, review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure the medication error rate was less than five percent (Residents R11 and R27). Findings include: The facility's medication error rate was eight percent based on observation of 25 medication administration opportunities with two medication errors observed. Review of facility policy, Medication Administration-General Guidelines, dated 2009, revealed .Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications and . the resident is always observed after administration to ensure that the dose was completely ingested. Further review of the policy indicated that, . Medications are administered within (60 minutes) of scheduled time, except before or after meal orders, which are administered (based on mealtimes). Observation of the medication pass, on December 2, 2015, at 8:30 a.m., with Employee E4, registered nurse, revealed that Employee E4 poured [MEDICATION NAME] 17 grams (gm.) into four ounces of orange juice, stirred the medication in the juice, then proceeded to administer the medication to Resident R11. Resident R11 drank approximately half of the juice, which contained the [MEDICATION NAME], then set the cup down on the overbed table. The employee subsequently left the resident's room. The juice cup with the [MEDICATION NAME] medication was left at the resident's bedside. Interview with Employee E4, registered nurse, immediately following the observation, confirmed that the employee was aware that the medication had been left at the resident's bedside. Further interview with the employee revealed that the employee planned on notifying the resident's certified nursing assistant (CNA) that the resident needed to finish the orange juice. Interview with the Director of Nursing on December 2, 2015, at approximately 2:00 p.m., confirmed that it is not an acceptable practice for nursing staff to leave medication at resident's bedsides for nursing assistants to monitor. Observation of the medication pass, on December 2, 2015, at approximately 8:35 a.m., with Employee E3, licensed practical nurse, revealed that Employee E3 administered [MEDICATION NAME] ([MEDICATION NAME]-medication to treat underactive [MEDICAL CONDITION]) 88 micrograms (mcg) orally, to Resident R27. At the time of the observation, the resident was seated in a chair in the resident's room eating breakfast. Review of the clinical record for Resident R27 revealed a physician's orders [REDACTED]. Interview with Employee E3 immediately following the observation, confirmed that the resident had consumed a portion of the breakfast meal prior to the administration of [MEDICATION NAME]. The facility failed to ensure that the medication error rate was less than five percent. 28 PA Code: 211.9(a)(1)(b)(d) Pharmacy services. 28 PA Code: 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews and interviews, it was determined that the facility failed to follow physician's orders for laboratory studies and medication administration for two of 13 residents reviewed (Resident's R18 and R39). Findings include: Resident R18's physician's order sheet, dated October 14, 2012, revealed that the resident had a [DIAGNOSES REDACTED]. A further review revealed a physician's order, dated September 14, 2012, for laboratory studies to be completed bi-monthly for a Basal Metabolic Panel (BMP) and Complete Blood Count (Complete Blood Count). Review of documentation revealed that there was no laboratory testing for CBC and BMP completed after August 6, 2012. As of October 14, 2012, a BMP and CBC had not been obtained and there was also no evidence that the physician had been notified. This was confirmed in an interview by Employee E1, on October 15, 2012, at 10:30 a.m. Resident R39's physician order sheet, dated October 16, 2012, revealed that the resident had a [DIAGNOSES REDACTED]. A further review of Resident R39's clinical record, revealed an order for [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was also no evidence that the physician had been notified. This finding was confirmed by Employee E2, on October 16, 2012, at 10:40 a.m. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.