§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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's attending physician was notified timely about a change in condition for one of five residents reviewed (Resident 2), resulting in a delay in treatment.
Findings include:
The facility's policy regarding changes in a resident's condition or status, dated December 23, 2020, revealed that the nurse was to notify the resident's attending physician or the physician on call when there was a significant change in the resident's physical, emotional or mental condition, or a need to alter the resident's medical treatment significantly.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 16, 2021, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, and had diagnoses that included a severe intellectual disability. A nursing note dated October 4, 2021, at 7:18 p.m. revealed that the resident was on the floor next to her wheelchair at the nursing station. The resident was unable to explain what happened, had no signs of pain, had no pain with active range of motion (joint movement) to her extremities, and the physician and the resident's family member were notified. A nursing note dated October 5, 2021, at 5:35 p.m. revealed that the resident was moving all of her extremities without difficulty and there were no signs/symptoms of pain.
A nursing note for Resident 2, dated October 6, 2021, at 10:31 p.m., and completed by a licensed practical nurse, revealed that the resident was unable to hold her right leg/foot up when being transported by the nurse aide in her wheelchair. The resident was assisted to transfer into bed, and she would not assist with the transfer. Upon assessment, the resident's right leg was swollen and the resident complained of pain. The Registered Nurse Supervisor was notified and assessed the resident's right leg.
There was no documented evidence that the resident's physician was notified about this change in Resident 2's condition.
A nursing note for Resident 2, dated October 7, 2021, at 10:12 a.m. revealed that the resident was complaining of right knee and leg pain. The right distal femur (the large bone of the upper part of the leg) was edematous (swollen) compared to her left leg, there was mild discoloration noted on the patella (knee cap), and the physician was notified and ordered an x-ray of the resident's right hip, femur, and knee. A nursing note dated October 7, 2021, at 4:03 p.m. revealed that the x-ray results showed a fractured right femur, the physician was notified, and an order was received to send the resident to the emergency room. A social service note for Resident 2, dated October 20, 2021, at 12:09 p.m. revealed that the resident had surgery on October 8, 2021.
Interview with the Director of Nursing on December 7, 2021, at 11:15 a.m. confirmed that there was no documented evidence that Resident 2's physician was notified regarding the change in the resident's condition on October 6, 2021, and was not notified until the next day, October 7, 2021.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 01/13/2022
1. The facility notified the physician on October 7, 2021, at 10:12 am that Resident 2 had a change of condition at 10:31 pm on October 6, 2021.
2. 24-hour report will be reviewed in clinical meeting to ensure changes in condition of residents had the appropriate physician and family notification completed. If a notification was not completed, it will be done immediately following meeting. An afternoon clinical wrap up meeting to ensure items identified in morning meeting are followed up on.
3. Director of Education or designee will educate licensed nurses and agency licensed nurses on changes in condition and need to notify physician at the time of the change. System change includes the implementation of the afternoon clinical wrap up meeting.
4. Director of Nursing or designee will audit documentation of 5 residents for physician notification weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month.
5. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.
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