§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 and clinical record, and staff interview, it was determined that the facility failed to notify the resident's responsible party of a change in condition for one of 22 residents reviewed (Resident R61).
Findings include:
A facility policy entitled "Notification of Changes" last reviewed in June 2023, indicated that the facility must inform the resident's representative, or family member when there is a "Clinical Complication" an example of which was the development of Stage 2 (partial-thickness skin loss) skin breakdown.
Resident R61's clinical record revealed an admission date of 7/22/2022, with diagnoses that included Dementia, Type II Diabetes (condition of improper blood sugar control), Chronic Kidney Disease and Pain.
A progress note dated 12/13/23, documented that Resident R61 had newly developed two Stage 2 open areas around the buttocks area. There was no further documentation to indicate that Resident R61's responsible party was notified of these areas of skin breakdown.
During an interview on 2/28/24, at approximately 10:20 a.m. the Director of Nursing confirmed that Resident R61's responsible party was not notified of the areas of skin breakdown as required.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
| | Plan of Correction - To be completed: 04/01/2024
R61 family notified of reddened area from December 2023. DON or designee will review residents for notification to families of changes by DON or designee. Nursing staff in serviced concerning notification of families by DON or designee. DON or designee to perform audit to ensure families notified of new changes. Audit of 50% of residents to be conducted 3 days per week for 2 weeks then 25% of residents 1 time per week for 2 weeks, then monthly for 2 months. Results will be reviewed at QAPI, and committee to determine if further action is required.
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