§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 facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to timely notify the resident representatives of a positive Covid19 test for 14 of 31 residents reviewed (Residents 1-14).
Findings include:
Review of facility policy, "Change in a Resident's Condition or Status", revised February 2021, revealed that a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status.
Review of Resident 1's annual MDS (Minimum Data Set - periodic assessment of resident needs) dated June 1, 2022, revealed a BIMS (brief interview for mental status) score of 10, indicating moderate cognitive impairment.
Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.
Review of Resident 2's quarterly MDS assessment of May 20, 2022, revealed a BIMS score of 4, indicating severe cognitive impairment.
Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.
Review of Resident 3's annual MDS assessment of May 5, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.
Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.
Review of Resident 4's admission MDS assessment of May 3, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.
Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.
Review of Resident 5's quarterly MDS assessment of May 12, 2022, revealed a BIMS score of 4, indicating severe cognitive impairment.
Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.
Review of Resident 6's annual MDS assessment of March 3, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.
Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19,but failed to reveal timely notification to resident representative.
Review of Resident 7's annual MDS assessment of April 13, 2022, revealed a BIMS score of 1, indicating severe cognitive impairment.
Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.
Review of Resident 8's quarterly MDS assessment of April 14, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.
Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.
Review of Resident 9's quarterly MDS assessment of March 25, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.
Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.
Review of Resident 10's quarterly MDS assessment of March 29, 2022, revealed a BIMS score of 4, indicating severe cognitive impairment.
Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19.
Review of Resident 11's quarterly MDS assessment of May 30, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.
Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19.
Review of Resident 12's annual MDS assessment of April 20, 2022, revealed a BIMS score of 9, indicating moderate cognitive impairment.
Review of progress note of June 8, 2022, revealed resident tested positive for Covid 19.
Review of Resident 13's quarterly MDS assessment of May 31, 2022, revealed both short and long term memory impairment.
Review of progress note of June 8, 2022, revealed resident tested positive for Covid 19.
Review of Resident 14's quarterly MDS assessment of March 16, 2022, revealed a BIMS score of 11, indicating moderate cognitive impairment.
Review of progress note of June 9, 2022, revealed resident tested positive for Covid 19.
Further review of the clinical records revealed no evidence that that resident representatives were made aware of the resident testing positive for Covid 19.
Interview with the Nursing Home Administrator on June 23, 2022, at 11:45 confirmed that there was no documentated evidence of the notification.
28 Pa. Code: 211.5(f) Clinical records
Previously cited 5/19/22
28 Pa. Code: 211.12(d)(1) Nursing services
| | Plan of Correction - To be completed: 07/12/2022
The facility cannot retroactively correct the deficiency for notification of resident representatives of significant changes timely.
The facility will complete a 7 day look back of resident changes in condition to ensure timely notification of resident changes to responsible parties as necessary. The IDCP team will review progress notes in the daily clinical meeting to identify any resident representatives that may need notified of a resident significant change in condition.
The Director of Nursing/designee will educate licensed nurses on the policy entitled, "Change in a Resident Condition." The education will include notifying resident representatives when there is a significant change in the resident's physical, mental or psychological status as necessary.
Audits will be completed 3 x weekly x 4 weeks then monthly x 2 months. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
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