§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 a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely notify the resident's interested representative, of a change in condition, a significant weight loss for one resident and scheduled diagnostic testing with the potential need to alter treatment, for one resident out of 12 sampled residents (Resident 24, and 26).
Findings include:
The facility policy "Monitoring Resident's Weight" and "Notification of change", last reviewed by the facility in January 2022, indicated any resident with weight changes of 5 (five) pounds weight gain or loss, the resident will be reweighed at the time of the noted change in weight. The facility will immediately inform the resident, consult the physician and if known, notify the resident's legal representative or an interested family member per federal and state regulations and residents right to privacy. Nursing services shall be responsible for notifying the resident, the attending physician and interested family or responsible party when: any change in the resident's physical, mental or psychological status, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications, and any scheduled appointments.
A review of the clinical record revealed that Resident 24 was admitted to the facility on August 23, 2021, with diagnoses to include dementia (thinking and social symptoms that interfere with daily function), chronic obstructive pulmonary disease (COPD), and gastro-esophageal reflux disease (GERD), chronic kidney disease, fracture of first lumbar vertebra (a bone in your lower back) and left femur (long bone of your leg), cerebral infarction (stroke), protein calorie malnutrition, and peripheral vascular disease (slow and progressive circulation disorder).
A quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated November 24, 2021, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 15 (13-15 represents cognitively intact) and required staff assistance with bed mobility, transfer, toilet use, personal hygiene, and dressing.
Resident 24's clinical record reflected a primary representative (responsible party and emergency contact #1) as a family friend.
A continued review of the resident's clinical record weight record revealed the following recorded weights:
October 6, 2021 (10:03 AM) - 191.8 Lbs. November 8, 2021 (9:23 AM) - 178.2 Lbs. weight loss (7.09 %) in 33 days. January 13, 2022 (11:50 AM) - 170.6 Lbs. weight loss (11.05%) in 99 days. February 28, 2022 (11:48 AM) - 164.2 Lbs. weight loss (14.39 %) in 145 days. March 7, 2022 (10:46 AM) - 154.6 Lbs. weight loss (19.40 %) in 152 days. April 5, 2022 (4:31 PM) - 145.0 Lbs. weight loss (24.40 %) in 181 days.
There was no documented evidence that the facility had notified the resident's interested representative of the significant unplanned weight loss identified on November 8, 2021, until January 18, 2022, after the additional significant weight loss was noted on January 13, 2022.
A review of the clinical record revealed that Resident 26 was admitted to the facility on March 15, 2004, with diagnoses including Alcohol Induced Dementia (caused by long-term, excessive consumption of alcoholic beverages, resulting in neurological damage and impaired cognitive function).
Resident 26 was hospitalized on December 15, 2021, and returned to the faciltiy December 28, 2021, returning to the facility with a new diagnosis of congestive heart failure (A progressive heart disease that affects pumping action of the heart muscles).
A quarterly Minimum Data Set assessment dated March 3, 2022, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 9 (13-15 represents cognitively intact).
Resident 26's clinical record revealed that the resident had a stress test scheduled for January 21, 2022. There was no documentation present in resident's clinical record conducted during the survey of April 7, 2022, to indicate that the resident's responsible party was notified of the resident's scheduled appointment for a stress test.
Interview with the Director of Nursing (DON) on April 7, 2022, at approximately 9:50 AM, confirmed the facility failed to notify Resident 24's interested representative of the resident's he significant unplanned weight loss and failed to notify Resident 26's responsible party of a scheduled appointment for diagnostic testing.
28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services
28 Pa Code 201.29(a)(l)(2) Resident rights
| | Plan of Correction - To be completed: 05/10/2022
Resident 24 no longer resides in the facility. Resident 26's interested representative was made aware of the unplanned weight loss. His cardiac appointment for diagnostic testing was cancelled. Residents in the facility with demonstrated weight loss within the past 30 days will be reviewed by the interdisciplinary care team to ensure notification of responsible parties/interested representatives. Residents in the facility scheduled for upcoming outside appointments for diagnostic testing will be reviewed by the interdisciplinary team to ensure timely notification of the resident's responsible party/representative. Licensed nurses will receive in service training from the director of nursing or designee regarding notification of changes to include significant weight loss and scheduled appointments for outside diagnostic tests. Weekly audits of resident records to ensure compliance will be completed by nursing supervisors as assigned for 1 quarter. Results will be reported by the director of nursing during the monthly quality assurance committee meeting for 1 quarter. Date of Compliance: May 10, 2022
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