|§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
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).
Based on a review of clinical records, select facility policy and facility investigative reports and staff interview, it was determined that the facility failed to notify the resident's representative of accidents and injury for one resident out of nine sampled (Resident CR1).
A review of the facility policy entitled "Calls to a Physician, Residents, or Responsible party(s), Routine and Emergent for Notice of Change in Condition" revealed that for emergencies, the resident or designated responsible party is to be notified of the emergent changes. Licensed staff will call the responsible party noted on the face sheet. When the responsible party is unable to be reached by phone their alternate may be notified for contacting purposes only. Routine calls to the physician which are considered to be notification of x-rays or diagnostic studies within normal limits, notification of room change, routine daily departmental recommendations and orders needing his/her attention. The resident or responsible party is to be made aware of the routine changes in condition after the physician has been made aware. Licensed staff will call the responsible party noted on the face sheet. If notified by phone this must be documented, their response must also be documented on the chart with their return call and that they have confirmed receiving the new change in condition information with the staff member accepting the call.
A review of the clinical record revealed that Resident CR1 was admitted to the facility on December 20, 2019, with diagnoses that included hypertension, osteoarthritis and vascular dementia (form of dementia caused by an impaired supply of blood to the brain).
According to Resident CR1's face sheet, both her son and daughter were listed as the resident's representatives for notification purposes.
A review of the Resident CR1's clinical record revealed that on December 21, 2019, a nurse documented at 8:45 p.m. that the "resident fell in back room" and was "complaining of R \ hip pain, will not walk which walking is her baseline." The entry noted that "a message was left for the POA (power of attorney)." Further review of documentation revealed that the resident was sent to the emergency room for evaluation and nursing noted that "Life Geisinger (an area program for older adults designed to give them the support services they need to live at home) updated."
A review of information provided by the facility dated December 21, 2019, at 7:45 p.m. revealed that the resident's son was notified at 8:00 p.m. of the resident's fall that required transfer to the emergency room for an evaluation.
However, documentation in the clinical record dated December 22, 2019, at 6:30 a.m. revealed that upon return from the emergency room the facility "called son's # \ numerous times, kept saying # not in service, no other # noted."
There was no documented evidence that the facility attempted to contact the resident's daughter when the resident's son could not be reached for notification of the fall and hospital transfer.
A review of information provided by the facility dated December 29, 2019, at 6:15 p.m. revealed that the nurse was notified that Resident CR1 had a bruised area near her left eye, "origin unknown". According to the documentation, the resident's son was notified of the bruise at 7:10 p.m. However, a review of documentation in CR1's clinical record dated December 29, 2019, at 6:15 p.m. revealed that the nurse was notified of a bruised area to the resident's left eye area, "origin unknown." A call was placed to the RP (responsible party) the resident's son, "the call did not go through due to number not in service. Tried multiple times".
There was no documented evidence that the facility attempted to contact the resident's daughter when the resident's son could be reached for notification of the injury of unknown origin.
There was no documented evidence in the clinical record that either the facility had reached the resident's son or daughter to notify either of them of the resident's fall on December 21, 2019, and/or the bruise on the resident's left eye on December 29, 2019.
Interview with the Director of Nursing on February 18, 2020, at approximately 2:00 p.m., confirmed that Resident CR1's family member, identified as representative contacts, were timely notified of the resident's changes in condition.
28 Pa. Code 211.12 (a)(c) Nursing services.
28 Pa. Code 201.29(a) Resident rights
| ||Plan of Correction - To be completed: 03/25/2020|
Resident CR1 was discharged from the facility.
Current resident incident reports will be reviewed for the past 30 days for documentation of proper and timely notifications.
Notification of change policy updated and licensed nursing staff was in serviced on Notification of Changes to both resident's next of kin/POA and physician.
DON /designee will audit all incident/accident reports daily x 4weeks, weekly x 4 weeks, monthly x 3 months to ensure proper and timely notifications.
Results will be discussed and reviewed at the Monthly QAPI meeting x 3 months