§483.10(b)(3) In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated. (i) The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the representative. (ii) The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law.
§483.10(b)(4) The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law.
§483.10(b)(5) The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law.
§483.10(b)(6) If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns when and in the manner required under State law.
§483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident's behalf. The court-appointed resident representative exercises the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. (i) In the case of a resident representative whose decision-making authority is limited by State law or court appointment, the resident retains the right to make those decisions outside the representative's authority. (ii) The resident's wishes and preferences must be considered in the exercise of rights by the representative. (iii) To the extent practicable, the resident must be provided with opportunities to participate in the care planning process.
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Observations:
Based on clinical record review and staff interview it was determined that the facility failed to afford a resident's designated representative the right to make health care decisions on the resident's behalf for one resident out of six sampled (Resident CR1).
Findings include:
A review of the clinical record revealed that Resident CR1 was admitted to the facility on March 3, 2020, with diagnoses that included ascites [is the buildup of fluid in your belly, often due to severe liver disease], chronic kidney disease 3A [moderate kidney damage and noticeable loss of kidney function], unspecified dementia [confusion or mild cognitive impairment can't be clearly diagnosed as a specific type of dementia], and cognitive communication deficit [deficits result in difficulty with thinking and how someone uses language].
A readmission Minimum Data Set Assessments (MDS -a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated November 10, 2023, indicated that Resident CR1 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status (BIMS is a brief screener that aids in detecting cognitive impairment scores of 13-15: cognitively intact, 8-12: moderately impaired, and 0-7: severe impairment).
A review of Resident A1's clinical record revealed that she was admitted to the facility on July 28, 2023, with diagnoses that included unspecified dementia, late onset Alzheimer's dementia, and major depressive disorder. Resident A1's MDS assessment dated November 23, 2023, and was severely cognitively impaired with a BIMS score of 2.
A review of Resident CR1's clinical record revealed an entry by the Certified Registered Nurse Practitioner dated January 4, 2024, indicating that the resident was not responding verbally, had labored breathing, and was ill-appearing with mottled skin. The CRNP progress noted that the resident's daughter, Resident A1, was brought to the resident's bedside, and Resident CR1's code status was discussed, and a hospice consult was ordered.
Further review of Resident CR1's clinical record revealed that the CRNP discussed changing Resident CR1's code status to a do not resuscitate (DNR) and end of life care with Resident A1.
Continued review of Resident CR1's clinical record revealed that Resident A1 was not listed in Resident CR1's clinical record as the resident's designated representative or emergency contact. The resident's other daughter, who did not reside in the facility, was designated as the resident's representative and first primary contact. The resident's grandson was identified as the second emergency contact.
A review of physician's orders dated January 3, 2024, at 11:58 a.m., revealed that Resident CR1's code status was changed from a full code to a do not resuscitate (DNR) and to consult hospice.
During an interview with the facility's CRNP on January 24, 2024, at 10:23 AM, the CRNP stated that she spoke with Resident CR1's daughter, Resident A1, because she was present in the room when she was evaluating with the resident The CRNP reported that despite Resident A1 having severe cognitive impairment, she felt that she would be able to make decisions for her mother \ and allowed Resident A1 to make the decision to change Resident CR1's code status from a full code to a DNR and decline further treatment on Resident CR1's behalf. The CRNP confirmed that she did not review Resident CR1's clinical record to identify who was the resident's designated representative and emergency contact prior to discussing end of life care with an Resident A1 who was not listed as a contact person for Resident CR1. The CRNP verified that she was unaware that Resident A1 was not designated as Resident CR1's representative or emergency contact or an individual to be contacted to make health care decisions on behalf of Resident CR1.
Interview with the Nursing Home Administrator (NHA) on January 24, 2024, at 11:45 a.m., confirmed that the facility failed to afford Resident CR1's representative the right to make decisions to change the resident's code status changes and end of life care. The NHA verified that the resident's designated representative and primary emergency contact should have been consulted for these decisions, which were made by Resident A1. The NHA also confirmed that the CRNP should have reviewed Resident CR1's record for the designated contacts before discussing the resident's health care decisions with Resident A1.
28 Pa. Code 201.18. (e)(1) Management.
28 Pa. Code 201.29 (a) Resident rights
| | Plan of Correction - To be completed: 02/09/2024
1. Resident CR1 is expired. 2. Facility completed baseline audit of current resident's face sheets to ensure correct Resident Representative's are listed in correct order. 3. Facility implemented new system that the Social Services Director will be responsible for updating face sheets when there is a change in BIMS per MDS. NHA educated Social Services Director on this process. Facility educated licensed nursing staff and licensed professionals on reviewing face sheet before having discussions to ensure they are speaking with correct resident representative. 4. DON/designee will audit any code status changes weekly for 4 weeks and then monthly for 2 months to ensure the correct resident representative was contacted. 5. Audits will be submitted to QAPI for review.
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