§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).
§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
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Observations:
Based on clinical record reviews, interviews with staff, facility documentation, policy and procedure reviews and interviews with family members, it was determined that the facility failed to notify the resident's representative of a need to alter treatment significantly and failed to notify the resident's physician of an accident requiring physician intervention for two of 23 residents reviewed. (Residents R96 and R97)
Findings include:
A review of the facility policy titled Notification of Changes revealed that it was the responsibility of the facility to immediately inform each resident and/or resident representative of accidents that have the potential for physician intervention or significant changes in condition. The policy also indicated that it was the facility's responsibility to ensure that the physician was immediately notified of an accident that had the potential for requiring physician intervention. The policy said that the physician was to be notified immediately of a significant change in physical, mental and psychosocial status of the resident.
Clinical record review for Resident R96 revealed that this resident was admitted to the facility on February 10, 2024. The nursing progress note indicated that Resident R96 had poor cognitive status. The nurse indicated that the resident's diagnosis upon admisssion was CVA (cerebral vasculer accident) with right sisded weakness and aphasia (a loss or impairment of one's capacity to use or comprehend language, which is most commonly caused by injury to a specific area in the brain).
Clinical record review on February 13, 2024 indicated that Resident R96 received testing for the virus that causes COVID-19 and the test results were positive. The nursing progress note on February 13, 2024 indicated that interventions were significantly changed for Resident R96 to include taking transmission based precaustions when providing care or visiting this resident. The nursing progress note dated February 15, 2024 indicated that Resident R96 had a persistent cough.
Interview with Resident R96's responsible party/family member at 1:00 p.m., on February 27, 2024, revealed that the family member was not notified of the need to alter Resident R96's treatment and care due to the fact that Resident R96 was diagnosed as being positive for the virus that causes COVID-19 on February 13, 2024. The family member reported visiting the facility on February 14, 2024 and having to ask nursing staff, the medical status of Resident R96.
Interview with Employee E2, the Director of Nursing, at 9:00 on February 28, 2024 confirmed that the facility had no documentation to indicate that the responsible party for Resident R96 was notified of a significant change (postive results for COVID-19 testing) or change in medical status on February 13, 2024.
Clinical record documentation for Resident R97 indicated that this resident was admitted to the facility on January 9, 2024 and had diagnoses of osteoporosis (brittle bones), rheumatoid arthritis(autoimmune disease of joint swelling, redness or warmth) and infection of the internal fixation device of the ulna (forearm).
Clinical record review for Resident R97 revealed that the resident reported to the Licensed nurse on February 8, 2024 that she had fallen from the toilet, in the bathroom on February 7, 2024, at approximately 6:00 p.m. The nursing assistant responsible for this resident reported that she was clearing a path or clearing the room to the resident's bed, when she saw the resident fall in the bathroom.
Review of facility's investigation of alleged abuse, neglect and misappropriation of property dated February 8, 2024 indicated that the nursing assistant assigned to provide care to Resident R97 failed to report to the licensed nurse that Resident R97 experienced a fall on February 7, 2024. The fall occurred in the bathroom on February 7, 2024 for Resident R97. After the fall occurred, the nursing assistant responsible for Resident R97 asked another nursing assistant to assist the resident from the floor and they placed Resident R97 into the wheelchair and into bed on February 7, 2024.
Continued review of the faciltiy's investigation revealed that the resident's incident/accident was consequently not reported to the physician, by the licensed nurse, on February 7, 2024, for required intervention post fall. The investigation report form indicated that the facility was not aware of any incident/accident for Resident R97 until the resident reported the incident on February 8, 2024.
Interview with the Director of Nursing, Employee E2, on February 29, 2024 confirmed that lack of notification of the physician of an incident/accident (fall) involving Resident R97 on February 7, 2024. Employee E2, Director of Nursing also confirmed that the lack of notification of the physician, resulted in a delay of assessment, monitoring and potential treatment for Resident R97.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 04/30/2024
1. Family was immediately notified of resident's condition, + covid and need for isolation. Documentation completed. As soon as Nursing Management made aware of fall, MD notified, assessment done (no injury) and monitoring initiated.
2. Audit immediately done for all other residents with isolation need r/t + covid. Documentation shows that all families had been notified. Will review fall incidents for past 30 days to ensure notification to MD was done timely, with appropriate assessment and monitoring.
3. Licensed Nurses to be educated to notify families (as appropriate) with a resident's change in condition r/t + covid and need for isolation. CNAs are being educated to immediately report fall to licensed nurse and wait for nurse to assess before picking up resident. DON/ADON/Nursing Supervisor will review all incident reports to ensure timely notification. DON/ADON/Nursing Supervisor will review 24hr report to ensure the above.
4. DON/ADON will audit weekly x4 and then monthly x2 for compliance. Results will be presented in QAPI.
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