§483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:
§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.
§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.
§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
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Observations:
Based on a review of closed clinical record review and staff interviews, it was determined that the facility failed to involve the resident's representative in the treatment decision and communicate treatment decision involving testing for one of three sampled residents (Closed Resident Record CR1).
Findings include:
Review of Closed Resident Record CR1's admission record indicated he was admitted on 5/12/26.
Review of Closed Resident Record CR1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/18/26, indicated he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), and anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry).
Review of Closed Resident Record CR1's care plans, indicated to assist with activities of daily living, dressing, grooming, toileting, feeding, and oral care.
Review of Closed Resident Record CR1's Certified Registered Nurse Practitioner (CRNP) note dated 5/13/26, indicated he was recently admitted. Resident CR1 was aggressive and combative.
Review of Closed Resident Record CR1's clinical nurse note dated 5/13/26, indicated that Resident CR1's family continued to request a TV in his room and because of his increased behaviors they would like a Urinary analysis done to rule out a urinary tract infection (UTI).
Review of Closed Resident Record CR1's dated 5/13/26 to 5/18/26 did not indicate that a urinary analysis was completed to rule out a UTI.
Review of Closed Resident Record CR1's Certified Registered Nurse Practitioner (CRNP) note dated 5/15/26, indicated he was aggressive and combative. Resident CR1 was not eating well, throwing food, throwing objects at staff, and would not allow staff to examine him. Resident CR1's daughter was present and stated he was not like this before.
Review of Closed Resident Record CR1's clinical nurse notes 5/16/26, resident refusing meds, slapping nurse on arm, pushing staff away; he continued to loudly yell out.
Review of Closed Resident Record CR1's clinical nurse notes dated 5/18/26, indicated he was up in his chair throwing cups and other things across the dining room. Resident CR2 was spitting on staff.
Review of Closed Resident Record CR1's clinical physician notes dated 5/18/26, indicated family was adamant Resident CR1 go to the Emergency Room despite being counseled that he may return to the facility within a few hours if no acute problems are found.
Review of Closed Resident Record CR1's clinical nurse notes dated 5/18/26, indicated Resident CR1 was sent to the hospital. Supervisor aware.
Review of Closed Resident Record CR1's clinical nurse notes dated 5/19/26, indicated Resident CR1 returned from emergency room. Has new order for Cefuroxime 500 mg (antibiotic to treat bacterial infections), twice a day for seven days. Diagnoses of UTI.
Review of Closed Resident Record CR1's clinical nurse notes and physician notes did not indicate any communication with the family representative explaining why a urinary analysis was not done between 5/13/26 and 5/18/26.
During an interview on 7/8/26, at 9:55 a.m. Licensed Practical Nurse (LPN) Employee E3 was asked if resident representative request labs test be completed, what is course of action, and she stated: "let the nurse supervisor know or pass it along to the doctor or CRNP. Let them know if there are any signs or symptoms. Once doctor puts in the order, get whatever lab test they are requesting. Make sure to tell someone."
During an interview on 7/8/26, at 10:03 a.m. Registered Nurse (RN) Supervisor Employee E6 was asked if family request labs be done, what is the course of action: "I would let the doctor know and then get the order. Lab results are printed or scanned into the record."
During an interview on 7/8/26, at 11:49 a.m. Nurse aide (NA) Employee E8 was asked if Resident CR1 had behaviors like throwing water and food: "yes, he threw everything. He would say he threw food for attention. He would refuse drinks."
During an interview on 7/9/26, at 12:16 p.m. information was disseminated to the Nursing Home Administrator (NHA), Interim Nursing Home Administrator (NHA) Employee E1, Regional clinical coordinator Employee E2, and the Infection Control Preventionist Employee E7 that the facility failed to involve the resident's representative in the treatment decision and communicate treatment decision involving testing for Closed Resident Record CR1 as required.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(2) Management.
28 Pa. Code 201.29(a): Resident rights.
| | Plan of Correction - To be completed: 08/03/2026
Preparation and submission of this POC is required by state and federal law. This POC
does not constitute an admission for purposes of general liability, professional
malpractice or any other court proceeding.
The facility is not able to correct the situation related to Resident CR1 as resident is no longer in the facility.
The Director of Nursing/designee will complete a 14 day look back to ensure the resident's representative was involved and notified in the treatment decision and communicated any treatment changes.
The licensed nursing staff will be re-educated on the facility policy for notification and communication on change in condition or treatment by the Director of Nursing/designee. The Director of Nursing/designee will review facility 24-hour report during morning clinical meeting to ensure resident representatives were involved and notified in the treatment decision and communicated any treatment changes.
The Nursing Director of nursing will audit five resident records daily for two weeks, three times a week for two weeks, weekly for two weeks and then monthly for three months to ensure resident representatives were involved and notified in the treatment decision and communicated any treatment changes. Results of audits will be submitted to the Quality Assurance Performance Improvement Committee for review and recommendations.
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