§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 review of the facility's policy, clinical records, hospital records, and interviews with staff, nurse practitioner, resident, and family, it was determined the facility failed to timely notify and report accurate information of a resident's change in condition to the physician for one of two residents reviewed (Resident 1). This failure resulted in actual harm of the resident when they were hospitalized, requiring intubation, mechanical ventilation, and ICU (Intensive Care Unit) admission for monitoring.
Findings Include:
Review of the facility's policy titled "Resident Change in Condition Policy," last reviewed on June 2, 2025, revealed "The licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Provider and the family/Responsible Party will be notified as soon as the nurse has identified the change in condition.
Review of Resident 1's diagnosis list includes Multiple Sclerosis (condition that causes breakdown of the protective covering of nerves; causing numbness, weakness, trouble walking, vision changes, and other symptoms) Neurogenic bladder (occurs when nerve damage disrupts the communication between your brain, spinal cord, and bladder muscle), and UTI (Urinary Tract Infection).
Review of Resident 1's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) assessment dated June 4, 2026 revealed the resident had a Basic Interview for Cognitive Status score of 15 indicating the resident had no cognitive impairment.
Review of Resident 1's active care plan revealed Resident had an altered elimination r/t (related to) suprapubic catheter (flexible tube inserted through the lower abdomen directly into the bladder to drain urine). The interventions include assessing/recording signs of UTI (pain, burning, blood-tinged urine, cloudiness, change in behavior), catheter output every shift, recording output amount every shift, and as needed.
Interview was conducted with Resident 1 on June 22, 2026, at 11:00 a.m. The resident, who was alert and oriented, revealed they had a catheter for a while now and had previous episodes of UTI. The Resident reported starting to have pain in their "private area" on Saturday (May 23, 2026) and reported to their nurse. The resident revealed they knew they were experiencing a UTI. Resident 1 further revealed feeling so sick they could not remember what happened for the next few days.
Review of Resident 1's nursing progress notes from a Licensed Practical nurse Employee E4 dated May 24, 2026, (10:33 a.m.), revealed "Resident c/o (complained of) difficulty urinating/pain at cath (catheter) site, states has a UTI. [resident] Thinks hasn't had a BM (bowel movement), and that's what may be blocking [resident]'s urine. Nsg sup (nursing supervisor) made aware and handling concerns."
Review of Resident 1's clinical record failed to reveal documentation indicating Resident 1's physician was notified of the resident's complaint of pain at the catheter site on the morning of May 24, 2026.
Review of Resident 1's progress notes failed to reveal documentation of the resident expressing pain in their private area.
Phone interview conducted with Resident 1's wife on June 22, 2026, (11:30 a.m.) revealed spouse called Resident 1 on May 24, 2026 (Sunday) by phone but was informed Resident 1 could not talk because resident was tired, not feeling well, and just wanted to sleep. Call from the nurse practitioner was received on May 25, 2026, around 9:00 a.m., and informed spouse of the resident "not feeling well," but vitals were normal, orders (lab studies, etc..) were initiated. The spouse revealed "it didn't feel right," so she decided to come to the facility to visit the resident. She got another call from the NP (Nurse Practitioner) while on the way to the facility and told them she was five minutes away. The wife reported that upon arrival, she observed the resident lying in bed, gurgling in the mouth, and not responding to her. She pressed the call bell and heard licensed nurse Employee E3 approaching and said, "I don't know who pressed the call bell, probably [they] recovered." The wife informed Employee E3 that she pressed the call bell and demanded Resident 1 be sent to the hospital immediately. 911 was called, and the resident was sent to the hospital.
Interview with Registered Nursing Employee E3 conducted on June 22, 2026, at 12:00 p.m., revealed Employee E3 was not notified of Resident 1's change in condition the morning of May 25, 2026. Employee E3 reported assessing the resident and observed the resident with a "decline, change in mental status, and not talking to me." Employee E3 confirmed he/she did not check the resident's vitals, and the information reported to the NP was from Licensed Practical Nursing Employee E4.
Interview with Licensed Practical Nurse, Employee E4 conducted on June 22, 2026, at 12:30 p.m. revealed Employee E4 reported the LPN (Licensed Practical Nurse) informs the Supervisor/RN's (Registered Nurses) of a resident's change in condition, and they are the ones who call the physician. Employee E4 confirmed reporting Resident 1's change in condition to Registered Nurse Employee E3 on May 24, 2026.
Continued interview with Licensed Practical Nurse (LPN) Employee E4 conducted on June 22, 2026, approximately 12:30 p.m., revealed the resident's vitals provided to Registered Nursing Employee E3 were the same vitals they documented on the nursing progress notes on May 25, 2026. Employee E4 further revealed "I cringed when I read [Employee E3] notes indicating the resident's vitals were within normal limits because it wasn't." The Blood pressure of 154/90 and heart rate of 111 were abnormal.
Phone interview with Nurse Practitioner (NP) Employee E5 was conducted on June 22, 2026, at 12:45 p.m. The NP confirmed their office did not receive a call from the facility the morning of May 24, 2026, regarding resident 1's complaint of pain at the catheter site. When asked what they would have done if they were notified, the NP responded, "I would have ordered to start IV (Intravenous - administered through veins) fluids and an antibiotic, [resident] gets septic quickly."
Continued phone interview conducted with Nurse Practitioner (NP), Employee E5, June 22, 2026, revealed as per documentation from the on-call NP on May 25, 2026, a call was received from the facility at 8:44 a.m., indicating Resident 1 was "lethargic" resulting in an order for IV fluids, antibiotic (Cipro), and lab work. The NP further revealed another call was received from the facility at 10:49 a.m., reporting the resident opens eyes but "was not themselves". The vitals reported to the NP by the nurse were HR- 76, B/P 128/74, R- 16, T-98.1, and Spo2 96%, which were all within normal range. The NP revealed a 3-way call with the facility and the wife was made to give an update on the resident's condition. At 1:30 p.m. on May 25, 2026, the office received another call from the facility indicating Resident 1 was sent to the hospital at 12:30 p.m., as requested by the wife. The NP revealed that based on the on-call NP's documentation on May 25, 2026, the on-call NP was not informed that the resident was clammy, pale, drooling, non-verbal, and with a HR of 111 as documented by Employee E4 on the morning of May 25, 2026. The NP further revealed they would have sent Resident 1 to the hospital immediately if they were provided with an accurate assessment. The NP further stated, "Assessment (of the resident) was presented differently to us."
Review of Resident 1's clinical record failed to reveal documentation indicating Resident 1's vital signs or urine output were monitored May 24, 2026, on the 3-11 (p.m.) and 11 p.m.-7 a.m. shifts.
Review of Resident 1's nursing progress notes dated May 25, 2026 (6:28 a.m.), revealed: "continue to c/o discomfort, pt (patient) in a stable condition, verbalize I think I have UTI, MD (physician) to be made aware."
Review of Resident 1's nursing progress notes authored by Licensed Practical Nurse, Employee E4 dated May 25, 2026, (10:48 a.m.), revealed "Resident was lethargic, drooling thick mucus, clearish [clear] pale yellow in color. Attempted to wake the resident up and open their eyes and touch their shoulder. [Resident] was not able to verbalize anything. The resident was clammy and pale in color. The resident has MS and has weakness, but the weakness on the L (left) side appears to be more than usual. No medications administered. Nsg. Sup, made aware and assessed. Nsg. Sup. to follow as Nsg. Sup had received orders from [physician company]." Continued review of same progress note revealed, "CNA (Certified Nursing Assistant) reported resident's condition to the nurse at 8:30 a.m." Vitals: HR (heart rate) 111 (normal range 60-100 bpm), R (respirations)- 16, 95% Spo2 in room air, B/P (blood pressure)- 154/90, T (temperature) - 97.8.
Review of Resident 1's nursing progress notes authored by Registered Nursing Employee E3 dated May 25, 2026, (12:18 p.m.), revealed "Assessed resident this a.m., and found to be arousable but not responsive. [Resident] vital signs were wnl (within normal limit) and were afebrile (no fever). Abdomen distended and hard, tried to irrigate the Foley, but it was blocked, so a new suprapubic catheter was inserted, returning 1000 of blood-tinged urine. The resident did become more comfortable, but still not responsive. [Provider's company] called and ordered an IV, but a site could not be found. [Provider's company] contacted again and stated wife is in transition to the facility, and she will make a determination for future orders. Wife arrived and stated that she wanted resident sent to [hospital], wife followed."
Review of Resident 1's hospital records including "Discharge Summary" dated May 31, 2026, revealed resident was admitted to the hospital on May 25, 2026, with diagnosis of Acute Respiratory Failure with Hypoxia (condition when lungs fail to adequately oxygenate the blood and remove carbon dioxide), Septic shock (severe and dangerous stage of sepsis, occurring when an infection triggers a systemic immune overreaction), Acute Kidney Injury and UTI.
Further review of the same report revealed "On arrival, [patient] was found to be profoundly hypoxic (state of inadequate oxygen reaching the body's tissues and cells to support normal functions) and Encephalopathic (condition that causes brain dysfunctions), requiring intubation and mechanical ventilation. [Patient] was managed in the ICU with full ventilatory support."
Interview with the Director of Nursing (DON) conducted on June 22, 2026, at 1:30 p.m. The DON denied that only the RN/supervisor can call the physician for a resident's change in condition.
The above findings were conveyed to the DON and NHA (Nursing Home Administrator) on June 22, 2026, at 1:45 p.m.
The facility failed to ensure Resident 1's change in condition was timely and accurately communicated with the physician resulting in actual harm when Resident 1 was admitted to the hospital to ICU on a ventilator with a diagnosis of septic shock and UTI.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing service
28 Pa Code 211.5(f) Clinical Records
28 PA Code 211.10(a) Resident care policies
| | Plan of Correction - To be completed: 06/25/2026
1) Resident 1 was hospitalized on 5/25/26 and treated for septic shock and UTI. Resident returned to facility on 5/31/26 with review by provider to ensure all care needs are in place and accurate.
2) All residents who have experienced a change in condition have the potential to be affected. DON/Designee completed a retrospective audit, 7 day look back of progress notes from date of survey exit 6/22/26 to ensure timely physician notifications for all residents who had experienced a significant change in condition.
3) To reduce the potential for reoccurrence, DON/ designee reeducated licensed staff on the resident change in condition policy w emphasis on timely physician notification and ensuring there is documentation of the communication and interventions in the EHR.
4) To monitor and maintain ongoing compline, DON/Designee will complete a 24 hour report audit review 5x per week to ensure resident changes in condition have been identified and appropriate physician notification has been in a timely manner.
5) Results of audits will be reviewed and revised as needed and discussed as needed to the QAPI committee.
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