§483.30 Physician Services
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.
§483.30(a) Physician Supervision.
The facility must ensure that-
§483.30(a)(1) The medical care of each resident is supervised by a physician;
§483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.
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Observations:
Based on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 2 residents with weight loss reviewed (Resident R4).
Findings include:
Facility Policy titled " Weight Policy NutraCo" reviewed " 12/2022 stated "any resident displaying a significant change in weight of greater than or equal to 5% gain/loss in one month will be reported to the Registered Dietitian and reweighed" under #7. Dietary interventions will be recommended as needed. All significant weight changes will be reported to MD".
Review of clinical documentation for Resident R4 revealed that that the resident was admitted to the facility March 8, 2018, with diagnoses of abnormal wight loss, vitamin D deficiency, difficulty in walking, muscle wasting and atrophy, legal blindness, other abnormalities of gait and mobility, peripheral vascular disease, dementia, and severe protein-calorie malnutrition.
Review of the resident's weight documentation revealed that on November 1, 2023, Resident R4 weighed 96.1 pounds and on February 5, 2024, the resident weighed 88.7 pounds which was unplanned weight loss of a -7.70% in three months, which met the criteria of a sever weight loss.
On March 5, 2024, at 12:30 p.m. an interview with the Registered Dietician, Employee E3 revealed that dietician did evaluate Resided R4 and implemented weight gain interventions. There was no documented evidence in the resident's clinical record that the physician assessment was completed related to unplanned weight loss.
Interview with the Nursing Home Administrator and the Director of Nursing on March 5, 2024, at 1:31 p.m. confirmed that there was no documentation from physician related to an assessment in regard to weight loss. It was not until March 5, 2024 that the physician was contacted and prescribed new orders for gastrointestinal (GI) council, mammogram and gynecology council to rule out abdominal cancer.
28 Pa. Code:211.12(d)(5) Nursing services.
28 Pa. Code:211.2(a) Physician services.
28 Pa. Code 211.5(f) Clinical records
| | Plan of Correction - To be completed: 03/27/2024
1) Resident R4 was reweighed on 3/5/24. The RD and physician were made aware of Resident #4's weight on 3/5/24. The physician evaluated Resident #4 on 3/17/24 with documentation of the visit in the medical record.
2) An audit was completed of residents with significant weight loss to validate that the physician evaluation was completed and documented. Variances were addressed at the time of the audit.
3) The DON/Designee re-educated the Unit Managers on the need to notify the physician for evaluation completion regarding residents with significant weight loss and validate that documentation of visit is maintained in the medical record.
4) The DON/Designee will complete 5 random audits of residents with significant weight loss to validate that physician notification and documentation of evaluation is in place for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
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