|§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 clinical record review and staff interview, it was determined that the facility failed to notify a resident's physician of a significant weight gain for one of 15 residents reviewed (Resident 16).
Review of Resident 16's clinical record revealed a diagnosis of congestive heart failure (CHF - a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues).
Review of Resident 16's August 2018 physician's orders revealed an order dated August 28, 2018 for daily weights for 5 days and to notify the physician if there was a greater than 3 pounds weight gain.
Review of Resident 16's weights revealed that the resident weighed 169 pounds on August 29, 2018 and 174.5 pounds on August 30, 2018, indicating a 5.5 pounds weight gain in 24 hours.
Review of Resident 16's clinical record failed to reveal evidence that the physician was notified of the 5.5 pounds weight gain on August 30, 2018.
Interview with the Director of Nursing on March 11, 2019 at approximately 10:20 a.m. confirmed that there was no evidence that Resident 16's physician was notified of the 5.5 pounds weight gain on August 30, 2018.
28 Pa Code 211.12(d)(1)(5) Nursing services
Previously cited 4/20/18
| ||Plan of Correction - To be completed: 04/19/2019|
Plan of Correction:
Resident 16 currently admitted to hospice services, weights not indicated at this time. Weight orders have been discontinued. Resident to continue to be provided comfort measures.
Residents with orders for daily/weekly weights will be reviewed and an initial list created. This list to be reviewed daily at morning standup by clinical team. Daily weight orders will be reviewed daily; weekly weights to be reviewed weekly; any significant changes per order parameters to be communicated with practitioner as ordered; list to be updated as needed
Nurses will be educated regarding the importance of notifying practitioner/Resident/RR of any change in clinical condition and document accordingly
Random audits to be conducted on residents with change in condition to monitor documentation of communication of any clinical changes with PCP/NP/Resident or RR by DON/Unit Manager/Designee weekly times 4 weeks, monthly times 3 months until 100% compliance is achieved
Results of all audits will be discussed at the facility's QA Committee meeting quarterly for additional recommendations if necessary