§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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's physician and responsible party of changes in condition for one of nine sampled residents. (Resident CL1)
Findings include:
A review of the facility policy entitled, "Notification of Change in Condition," revealed that staff were to notify the physician and resident representative immediately if there was a change in condition.
Clinical record review revealed that Resident CL1 was admitted to the facility on May 21, 2024, with diagnoses that included metabolic encephalopathy (brain dysfunction) and repeated falls. On May 28, 2024, a nurse noted a reddened moisture associated skin dermatitis to Resident CL1's sacrum. There was no documented evidence that Resident CL1's physician and resident representative were made aware of the change in condition.
In an on June 8, 2024, at 1:41 p.m., the Registered Nurse Supervisor (RN 1) confirmed there was no evidence that Resident CL1's physician and resident representative were notified of the change in condition.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 07/08/2024
Resident CL1 was discharged from facility at time of complaint survey
A 30 day chart review on skin assessments will be performed to ensure all responsible parties and physicians were notified
Licensed nursing staff will be re-educated by NPE or Designee on "Notification of Change in Condition" policy. Changes in Condition will be reviewed by IDT and/or Designee to ensure resident change in Condition is reported to physician and family/representative timely.
Nursing staff will review nursing notes daily noting a change in condition to ensure the physician and family/representative were notified. Center will conduct an audit of 5 changes in condition weekly x 4, monthly x 6 for physician and family notification.
The DON/Designee will report findings during next months QAPI meeting x 6 months.
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