§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 clinical records and staff interview, it was determined that the facility failed to notify the resident's interested representative of the need to alter treatment as the result of the reoccurrence of a pressure sore for one resident out of 8 sampled (Resident CR1).
Findings include:
A review of the clinical record revealed that Resident CR1 was admitted into the facility on October 17, 2020, with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), skin cancer of the left lower limb, and diabetes.
A review of Resident CR1's clinical record revealed that on August 31, 2023, a stage 1 pressure area was identified on the resident's coccyx and treatment to the area was initiated.
A review of Resident CR1's wound evaluation flow sheet dated October 13, 2023, revealed that the resident's coccyx pressure wound had "healed."
According to the resident's Treatment Administration Record, treatment to the area with peri-guard continued until October 24, 2023.
On October 25, 2023, the treatment was ordered to be changed to skin prep to coccyx two times a day for two weeks.
A review of nursing documentation dated October 27, 2023, at 5:09 PM revealed that Resident CR1 experienced a change in condition. During nursing observation of the previously healed stage 1 pressure sore on the resident's coccyx, revealed that a "small break in skin integrity" was now identified.
According to the nursing documentation, the resident's daughter/RP was "already aware of area as area being followed by nursing since September 13, 2023."
On October 28, 2023, the consultant wound care physician ordered Medi-Honey (wound gel used to promote healing) to be applied to the resident's pressure sore on the coccyx.
There was no documented evidence that the resident's interested representative, her daughter, was informed that the resident's pressure sore had reoccurred, as an open area, and was being treated by the wound care physician and the new treatment of Medi-Honey.
An interview with the Director of Nursing on January 22, 2024, at approximately 2:00 PM confirmed that the facility did not notify the resident's representative that the resident's had a current pressure sore and the treatment plan.
28 Pa Code 211.12 (d)(3)(5) Nursing services
| | Plan of Correction - To be completed: 03/04/2024
1. Facility cannot correct deficiency as it relates to resident CR1 as resident is deceased. 2. Licensed nursing staff to be educated on proper notification procedures to resident's representatives for changes in wounds and/or treatment changes. 3. DON/designee will audit nursing documentation residents with new or existing wounds to identify if notifications to resident representatives was completed. Deficiencies will be corrected. 4. DON/designee will provide audits to NHA weekly to ensure all audits are completed daily. Results will be reviewed by the QA committee X 3 months to ensure compliance. 5. POC compliance date 3/4/2024
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