§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 review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of missed medication doses for one of five residents reviewed (Resident R1).
Findings include:
Review of facility policy "Medication Shortages/Unavailable Medications" dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary.
Review of facility policy "Resident Change in Condition" dated 1/12/25, indicated the physician/provider and resident/family/responsible party will be notified when there has been a need to alter the resident's medical treatment, including a change in provider orders.
Review of the clinical record indicated Resident R1 was admitted to the facility on 9/5/23.
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and personal history of malignant neoplasm of prostate (prostate cancer).
Review of a physician order dated 3/11/25, indicated to administer Nubeqa (a medication given to decrease growth and spread of prostate cancer) 600 milligrams by mouth twice a day.
Review of Resident R1's April 2025 Medication Administration Record revealed the scheduled medication was not administered on the following: - 4/21/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: medication was reordered has not arrived" - 4/22/25 AM Med Pass, the documented reason was "Not Administered: Refused" - 4/22/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: family is to provide" - 4/23/25 AM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/23/25 PM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/24/25 AM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/24/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: family to supply" - 4/25/25 AM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/25/25 PM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/26/25 AM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/26/25 PM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/27/25 AM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/27/25 PM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/28/25 AM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/28/25 PM Med Pass, the documented reason was "Drug/Item Unavailable" - 4/29/25 AM Med Pass, the documented reason was "Drug/Item Unavailable: supplied by family; awaiting arrival"
During an interview on 4/29/25, at 9:56 a.m. the Director of Nursing (DON) stated, "Resident R1 was admitted in 2023 on this cancer medication. He's his own person, but he has a brother involved. This cancer medication is $1500 a month, his brother pays out of pocket for it. We recently found out that this brother is now unable to order and provide the medication. He got it from a pharmacy in Delaware. He has another brother who is willing to take over and supply the medication, however since Resident R1 is his own person and responsible party, we can't give the other brother any of his medication information without his permission and Resident R1 has stated he doesn't want us to talk to his brother."
During an interview on 4/29/25, at 10:41 a.m. the DON stated the facility was unable to provide documentation that the physician was made aware of Resident R1's medication being unavailable and that the facility failed to ensure the physician was appropriately notified of missed medication doses for Resident R1.
28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 05/15/2025
F580
1) R1's Physician was notified of the omitted medication From 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28 and 4/29/25. R1 has resumed the omitted medication on 4/30/25. 2) Facility audit of medication carts was completed to ensure no other residents have omitted medications requiring MD notification. 3) DON/Designee to educate nurses on "Medication shortages/Unavailable Medications" policy and "Resident change of condition Policy" by 15MAY2025 4) DON/Designee will conduct audit "Administration compliance Report" 3x week x 4 weeks then monthly x 2 for omitted medication To ensure notification of change in condition related to Medication unavailable. 5) The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation
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