§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).
|
Observations:
Based on clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for twelve of nineteen residents testing positive for Covid-19 (Resident R1, R2, R5, R7, R8, R10, R11, R12, R16, R17, R18, R19).
Findings include:
Review of the facility policy "Notification of Changes" last reviewed 2/15/23, indicate the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include but not exclusive to circumstances that require a need to alter treatment, significant change in the resident's physical, mental or psychosocial condition.
Review of Resident R1's clinical record indicated admission to facility on 9/11/20, with the diagnosis of Lymphoma (form of cancer), diabetes (high blood sugar levels) edema (swelling).
Review of facility covid line listing indicated Resident R1 tested positive for COVID-19 on 2/21/24.
Review of Resident R1's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R2's clinical record indicate admission to facility on 12/23/23, with the diagnosis of diabetes, Parkinson's disease (degenerative neurological disorder), hypertension (high blood pressure).
Review of facility covid line listing indicated Resident R2 tested positive for COVID-19 on 2/24/24.
Review of Resident R2's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R5's clinical record indicate admission to facility on 1/16/24, with the diagnosis of fracture of left femur (thigh bone), multiple sclerosis (autoimmune disease), dysphagia (difficulty swallowing).
Review of facility covid line listing indicated Resident R5 tested positive for COVID-19 on 2/16/24.
Review of Resident R5's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R7's clinical record indicate admission to facility on 1/12/24, with diagnosis of dementia (loss of memory), muscle weakness, gastro-esophageal reflux disease (GERD- stomach acid flows backwards).
Review of facility covid line listing indicated Resident R7 tested positive for COVID-19 on 2/16/24.
Review of Resident R7's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R8's clinical record indicated admission to facility on 3/3/23, with diagnosis of aphasia (loss of ability to understand or express speech), cerebral infarction (stroke), ataxia (loss of body movements).
Review of facility covid line listing indicated Resident R8 tested positive for COVID-19 on 2/22/24.
Review of Resident R8's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R10's clinical record indicated admission to facility on 12/25/29, with diagnosis of cerebral infarction (stroke), diabetes, aphasia (loss of ability to understand or express speech).
Review of facility covid line listing indicated Resident R10 tested positive for COVID-19 on 2/16/24.
Review of Resident R10's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R11's clinical record indicated admission to facility on 1/22/24, with diagnosis of diabetes, dysphagia, hypertension.
Review of facility covid line listing indicated Resident R11 tested positive for COVID-19 on 2/16/24.
Review of Resident R11's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R12's clinical record indicated admission to facility on 2/7/24, with diagnosis of atrial fibrillation (A-fib rapid irregular heartbeat), weakness.
Review of facility covid line listing indicated Resident R12 tested positive for COVID-19 on 2/16/24.
Review of Resident R12's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R16's clinical record indicated admission to facility on 8/24/22, with diagnosis of emphysema (lungs are damaged), neutropenia (low white blood cells), gastritis (inflammation of the stomach).
Review of facility covid line listing indicated Resident R16 tested positive for COVID-19 on 2/16/24.
Review of Resident R16's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R17's clinical record indicated admission to facility on 12/18/23, with diagnosis of diabetes, muscle weakness, hyperlipidemia (high fat in blood).
Review of facility covid line listing indicated Resident R17 tested positive for COVID-19 on 2/16/24.
Review of Resident R17's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R18's clinical record indicated admission to facility on 8/22/23, with diagnosis of multiple rib fractures, hyperlipidemia, hypertension.
Review of facility covid line listing indicated Resident R18 tested positive for COVID-19 on 2/18/24.
Review of Resident R18's progress notes did not include information on physician notification of COVID-19 testing results.
Review of Resident R19's clinical record indicated admission to facility on 2/13/24, with diagnosis of intercranial injury (injury of brain), GERD, hyperlipidemia.
Review of facility covid line listing indicated Resident R19 tested positive for COVID-19 on 2/18/24.
Review of Resident R19's progress notes did not include information on physician notification of COVID-19 testing results.
Interview on 3/18/24, at 2:14 p.m. the Nursing Home Administrator confirmed the facility failed to notify the physician of a change in condition for twelve of nineteen residents testing positive for COVID-19. (Resident R1, R2, R5, R7, R8, R10, R11, R12, R16, R17, R18, R19).
28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
| | Plan of Correction - To be completed: 04/30/2024
- Doctor was notified of all affected residents R1, R2, R5,R7,R8,R10,R11,R12,R16,R17,R18,R19 and their COVID-19 positive status from outbreak.
- An audit was completed of all like residents to ensure all doctor notifications were complete for residents affected by the outbreak.
- Licensed nurses and Infection Preventionist will be re-educated by DON or designee on policy for notification of any changes in condition to physician.
- All residents will be audited twice weekly for 2 weeks then weekly going forward, for any changes in condition and notification to physician being completed. Any resident that has a change in condition, will have a proper note and documentation of change with physician notification.
|
|
