§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 clinical record review and staff interview, it was determined that the facility failed to notify the resident representative of a change in condition for one of seven sampled residents. (Resident 1)
Findings include:
Clinical record review revealed that Resident 1 had diagnoses that included chronic respiratory failure, seizures, and diabetes. The Minimum Data Set assessment, dated May 13, 2024, indicated that the resident had cognitive impairment. Review of a nurse's note dated June 30, 2024, revealed that Resident 1's right buttock was observed to be red and irritated with new orders from the physician to cleanse the area with normal saline solution, pat dry, and apply barrier cream and a foam border dressing. Review of a wound care progress note dated July 19, 2024, revealed that Resident 1 had a new left-sided anterior neck abrasion with orders to cleanse with wound cleanser and leave open to air. There was no documented evidence that the resident's representative was notified of the changes in condition.
In an interview on July 30, 2024, at 12:45 p.m., the Director of Nursing confirmed that the resident's representative was not notified of the changes in condition.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 09/13/2024
F 0580
SS=D
Resident 1 is currently at the hospital.
An audit will be conducted to ensure all changes in condition for the last 30 days were reported to the Resident Representative.
Staff will be re-educated in the change in condition policy and procedure and the required notification of the resident/resident representative.
The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure the resident/resident representative are notified regarding a change in condition with the resident/patient.
Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.
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