|§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 facility policy, clinical records review, and staff interview, it was determined that the facility failed to timely notify the physician and the responsible party of a change in condition following a second fall for one of three residents reviewed (Resident R1).
Review of the facility's Clinical Practice Standards titled "Changes in Resident Condition", with a revision date of February 2017, revealed that the nursing staff, the resident and the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. A review of the same policy revealed that prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician's intervention; a significant change in the resident's attending physical, mental, or psychosocial status.
Review of Resident R1's clinical records revealed the following diagnoses not limited to weakness, essential hypertension (high blood pressure), Hypomagnesemia (below normal level of magnesium), Diabetes ( Failure of the body to produce insulin enable sugar to pass from the bloodstream cells for nourishment, Chronic Embolism, and Thrombosis of unspecified deep veins of lower extremity (A blood clot that has traveled through the veins and become stuck).
Review of Resident R1's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care), dated November 27, 2019, revealed that the Resident was cognitively intact. A review of the same MDS revealed that Resident R1 required extensive with one-person assistance with transferring and toileting but independent with ambulation inside the room.
Review of Resident R1's clinical records POLST (Physician Orders for Life-Sustaining Treatment) dated November 22, 2019, revealed that Resident R1 had an order for DNR (Do Not Resuscitate) and was on comfort measures.
Review of Resident R1's December 2019 physician order revealed that the Resident was both on Coumadin and Lovenox (a Blood thinner, medication that can treat and prevent blood clots) for diagnosis of Deep Vein Thrombosis (DVT- A blood clot that forms in a vein deep inside your body) on the left leg.
Review of the facility progress note dated December 18, 2019, revealed that Resident R1 had an unwitnessed fall during 6:00 p.m. to 7:00 p.m. medication pass, Resident was noted by the nurse on the floor on the right side with pants half-way off. Review of the same note revealed that the Resident was unable to describe what happened during the fall, no complaint of pain or discomfort, no signs, and symptoms of distress, no injury noted, safety measures ensured, call bell within reach, nursing will continue to monitor.
Review of the incident report dated December 18, 2019, at 6:55 p.m., revealed that the resident was noted on the floor on right side bedside with pants half-way off, bed noted at the lowest position, unable to describe what happened during the fall, no complaints of pain and discomfort. Additional review of the same form revealed that the Resident was alert and oriented to person and place, zero level pain and ambulatory without assistance. The incident report also revealed that the physician was notified of the fall at 7:00 p.m., and the responsible party was notified at 7:05 p.m. Neurological record (used to assess an individuals neurological functions and level of consciousness in order to determine whether or not individual is functioning properly and reacting appropriately to the tests being performing) revealed that neulogical assessment was conducted and completed by the facility.
A review of a physician note documented by the nurse practitioner on December 18, 2019, at 7:39 p.m., revealed: "Patient was seen for follow up, nursing concerned with increased weakness per Physical Therapy (PT), the patient was dragging her feet in the therapy today. Nursing also concerned the patient is more depressed, not participating in her care as frequently". A review of the same progress note revealed no mention regarding the fall. Further review of the same note revealed that the nurse practitioner assessed the Resident and revealed the following; blood pressure was 148/80, pulse rate of 74, respirations of 18 and temperature was 98.7 Fahrenheit; Neuro: Alert, oriented x3, follows the command. The nurse practitioner ' s plan of care included the following: For increased weakness/ change in mental status, collect UA CS (Urinalysis, culture, and sensitivity), monitor, fall precaution. For depression, increased Zoloft (medication to treat depression) to 75 milligrams and continue supportive care. For difficulty in walking, continue with PT/OT (physical therapy/occupational therapy), use assistive devices. The nurse practitioner also ordered blood works for December 20, 2019.
Review of the facility progress note dated December 19, 2019, at 3:00 a.m., revealed: " Called to room [room number] by charge nurse stating the Resident was on the floor, observed resident lying on her right side on the floor facing the door, upon assessment no apparent injury noted, complained of generalized pain, Tylenol administered, neuro check initiated, nursing will continue to monitor".
Review of the facility documentation, incident report dated December 19, 2019, at 6:50 a.m. revealed that the Resident was found on the floor laying on right side of hip with hands in-between legs, appears alert and oriented to self and situation, reported pain of seven on a pain scale of zero to ten, pupils reactive, no signs and symptom of shortness of breath. Supervisor, physician and family member made aware, will continue to monitor. Further review of the same report revealed that through a French interpreter, the Resident stated: "I want to go to the bathroom and fall". The additional review revealed that the Resident had a pain on the front left thigh and front left knee with a pain level of seven (moderate pain). Level of consciousness was alert and oriented only to person and situation and mobility was ambulatory with assistance which was a change from the last assessment following the first fall.
A review of the facility documentation revealed no exact time the resident fell the second time, but a review of the neurological record revealed that the neurological assessment
for Resident R1 was started on December 19, 2019, at 12:45 a.m.
A review of the facility progress note dated December 19, 2019, at 6:35 a.m., revealed that specimens for urinalysis could not be collected, The resident had a fall and was not able to ambulate to use the bathroom, was incontinent during the shift.
Review of the facility documentation SBAR Summary (A form of communication to facilitate a prompt and appropriate communication) dated December 19, 2019, at 4:40 a.m. revealed that the Resident Care Specialist (RCS- nurse aide) reported seeing resident on the floor while doing her round. A review of the same document revealed that the physician was not notified of the second fall on December 19, 2019, until 6:00 a.m., and the responsible party was not notified of the second fall until 6:07 a.m., despite the changes observed after the second fall.
A review of the facility documentation revealed no information if the physician made any recommendation when she/he was notified of the second fall at 6:00 a.m.
Interview with the Assistant Director of Nursing on December 26, 2019, at approximately 2:00 p.m., revealed that the physician ordered to monitor the Resident after the second fall.
Review of the facility progress note dated December 19, 2019, at 12:47 p.m., revealed that Resident R1 was noted to be less conscious, not tolerating meds and meals, the physician was made aware, order to transfer the resident to the emergency room for evaluation. Review of the same notes revealed that the responsible party was notified of the Resident's change in condition.
Review of the facility progress note dated December 19, 2019, at 11:22 p.m., revealed that the resident was admitted for Subdural Hematoma at [Hospital name].
28 Pa. Code: 211.5(f) Clinical records
Previously cited 12/22/19, 9/3/19, 8/2/19
28 Pa. Code: 211.12(d)(1) Nursing services
Previously cited 12/22/19, 10/16/19, 9/3/19, 8/2/19
28 Pa. Code: 211.12(d)(5) Nursing services
Previously cited 12/22/19, 9/3/19, 8/2/19
| ||Plan of Correction - To be completed: 01/13/2020|
Preparation or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because the provisions of federal and state law require it. The plan of correction serves as the facility's allegation of compliance.
1. Resident is no longer at facility. Employee was provided education on timely notification of Physician and Responsible Party regarding change of condition.
2. 100% audit was completed for 12.26.2019 for the timely notification of Physician and Responsible Party to ensure no other residents were affected.
3. Licensed Staff will be educated on the timely notification of Physician and Responsible Party for a Change of Condition of resident.
4. SBAR will be monitored during clinical meeting to ensure timely notification of Physician and Responsible Party – any issues will be corrected immediately and any trends will be submitted to QAPI for further recommendations.