|§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 review of clinical records and staff interview, it was determined that the facility failed to timely consult with the physician and notify the resident's representative of significant weight losses for two residents out of five sampled (Resident 52, and 75).
A review of facility policy entitled "Notification in Change" last reviewed January 2021, revealed the nurse will notify the resident, resident's physician, and the resident representative for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. The facility will document the notification and record any new orders in the resident's medical record.
A review of the clinical record revealed that Resident 52 was admitted into the facility on June 23, 2020, and has diagnoses including cerebral infarction (stroke), dysphagia (difficulty swallowing), and hypertension.
A review of the resident's weight record revealed that the resident weighed 135.6 pounds on July 1, 2020. When the resident was weighed on August 5, 2020, it was noted that the resident's weight had decreased to 122 pounds. The resident had a 13.6 pound weight loss, which was a significant weight loss, of 10% loss of body weight in 30 days.
Nutrition/Dietary notes dated August 5, 2020, at 3:06 PM and August 11, 2020, at 1:04 PM identified the resident's weight loss, but there was no indication that the resident's representative was notified of the significant weight loss.
Further review of the resident's weight record revealed the resident weighed 117.6 pounds on November 12, 2020. The resident was weighed on November 25, 2020, and the resident's weight had further declined to 109 pounds. The resident had an 8.6 pound weight loss, which was a 7.31% weight loss in 2 weeks.
A Nutrition/Dietary note on November 25, 2020, at 2:02 PM, again noted the resident's weight loss, but there was no indication in this resident's clinical record that the resident's representative was notified of the weight loss.
Interview with the Nursing Home Administrator (NHA) on February 18, 2021, at approximately 3:00 PM confirmed that there was no documentation of notification of the resident's representative of the significant weight losses for Resident 52.
A review of the clinical record revealed that Resident 75 was admitted into the facility on May 3, 2019, with diagnoses that included Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves).
A review of the resident's clinical record indicated the resident weighed 126.4 pounds on December 2020. The resident was weighed on December 30, 2020 and was noted to weigh 118.8. lbs The resident had a 7.6 pound weight loss, which is 6 % in 30 days.
A review of the resident's clinical record revealed no documentation that the physician was notified of the resident's significant weight loss.
Interview with the NHA on February 18, 2021, at 12:30 PM confirmed that the facility failed to timely notify the physician of the resident' significant weight loss
28 Pa Code 211.12 (a)(c)(d)(3)(5)Nursing services
| ||Plan of Correction - To be completed: 03/30/2021|
Resident 52 and 75 weights are stable. Their Representatives and Physician have been made aware of their significant changes in condition (weight loss).
Currents residents have been reviewed and significant changes in conditions, related to weight, have been reported to their Representatives and Physicians.
Appropriate staff have been made aware of the need to notify significant changes in condition related to weights. The facility Dietary Manager, along with oversight of the Dietician, will ensure weights are monitored closely and significant changes reported to the RN Supervisors so notification can be made.
The DON/Designee will audit changes in condition, related to weights, to ensure proper notification. Findings of the audits will be reviewed at QA meeting for review and recommendation.