|§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
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).
Based on a review of clinical records and a facility investigative report and staff interviews it was determined that the facility failed to promptly notify the resident's physician of a change in condition for one of 15 residents reviewed (Resident 78).
Review of Resident 78's clinical record revealed admission to the facility on April 10, 2013, with diagnoses including Alzheimer's and Dementia (Non-Alzheimer's dementia) disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).
A review of the resident's quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 78, dated February 1, 2019, revealed that the resident had short- and long-term memory impairment, was moderately cognitively impaired and dependent on staff for bed mobility, transfer, dressing and eating.
Further review of the resident's clinical record revealed nursing documentation dated April 2, 2019, at 3:51 a.m. indicating that nursing was called to Resident 78's bedside because the resident's upper left arm was bruised. The bruising encompassed the resident's upper left arm, including the axilla (a person's armpit). The nurse called the physician and received a new order for X-rays of Resident 78's left humerus (upper arm bone) and shoulder, which revealed a fracture involving the humeral neck.
A facility investigative report dated April 2, 2019, at 3:51 a.m. identified a purple bruise on Resident 78's left upper arm.
A review of Employee 1's (Nurse Aide) witness statement (undated), accompanying this investigative report, indicated that on Saturday March 30, 2019, around 10:00-11:00 a.m. staff went to check on Resident 78, and put her back in bed. The resident's left arm was "down by her side" and staff "didn't think anything of it". Around 1:30 staff went in to change her and reposition the resident and noticed resident's "hand seemed to be bent to the side and her arm was back down by her side." Employee 1 summoned Employee 2, Nurse Aide, who agreed "something wasn't right" with Resident 78. Employee 2 "went to our charge nurse to report that something wasn't right with resident's left arm". "I (Employee 1) stayed over 2nd shift and reported the same thing to that charge nurse".
A review of Employee 2 (Nurse Aide) witness statement dated April 2, 2019 stated "I was working 11:00 a.m. to 3:00 p.m. Employee 1 came and asked me to look at Resident 78's arm, that it seemed limp. I looked at it, agreed with her and reported it to Employee 3 (Licensed Practical Nurse-LPN) who was my charge nurse."
A review of Employee 3, LPN's witness statement dated April 2, 2019, revealed that "On March 30, 2019, CNA came to me and stated that Resident 78's left arm was flaccid and not contracted per normal." "Assessed left arm and was noted to be very flaccid without rigidity". "Will monitor same."
A review of Employee 4, RN (Registered Nurse)'s witness statement dated April 3, 2019, revealed that "Employee 1 asked me if Employee 3 passed along about her (Resident 78) arm being flaccid. Was not assessed during my shift."
There was no documented evidence at the time of the survey ending April 30, 2019, that the licensed nursing staff, Employee 3 (LPN) or Employee 4 (RN) had notified the physician regarding the change in condition of Resident 78's her left arm, when identified on March 30, 2019. The physician was notified until April 2, 2019.
During an interview April 30, 2019, at approximately 1:00 p.m. with the Director of Nursing confirmed that the facility's licensed nursing staff had not timely notified the physician of Resident 78's change in condition.
28 Pa. Code 211.5(f) Clinical Records
Previously cited 7/13/18, 3/5/19
28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services
Previously cited 7/13/18, 3/5/19
| ||Plan of Correction - To be completed: 05/17/2019|
The physician was notified of the change in condition for resident 78 on April 2, 2019. Re-education provided to employee 3 and employee 4 on physician notification.
Review of 24 hour reports for the past 30 days to ensure any change in conditions have notification to the physician documented in the clinical record.
Licensed staff will be re-educated on physician notification with any change in condition of a resident.
Audit of 10% of clinical records will be completed by the DON/designee weekly x4 weeks, then monthly x2 to ensure any change in condition is updated to the physician. Results of audits to QA for review and recommendations.